Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Attached to
- Z2DA--626A4-19-101 - Renovate Ward 1B at the Alvin C. York VA Medical Center, Murfreesboro, TN 37129
- Solicitation number
- 36C24923R0114
About this file
This document contains a pre-award contractor safety evaluation form and information on a related federal contract opportunity for renovations at a VA medical center. The form requests safety information over the past three years including total man hours, OSHA recordable incidents, DART rates, and serious violations. It also asks for the company's NAICS code, safety program administrator, and experience modification rate. The related federal contract opportunity is a solicitation to renovate Ward 1B at the Alvin C. York VA Medical Center in Murfreesboro, Tennessee issued by the Department of Veterans Affairs Veterans Health Administration VISN 9. The solicitation number and additional identifying details are provided.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923R0114
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220
3. Who administers your company’s Safety and Health Program? ____________________________.
4. Company’s Insurance Experience Modification Rate (EMR): ____________________________
File details come from the government source that posted it. Updated .