Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- N041--626-24-201 - Replace Chiller #2 Tennessee Valley Healthcare System, Nashville Campus
- Solicitation number
- 36C24923B0023
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a federal solicitation to replace a chiller at the Tennessee Valley Healthcare System Nashville campus. The form requests information on the contractor's OSHA 300 forms from 2020 to 2022 including man hours, days away from work cases, and OSHA violation details. It also asks for the contractor's six-digit NAICS code for plumbing, heating, and air conditioning work as well as the administrator and experience modification rate of its safety and health program.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24923B0023 0003.pdf | ||
| PCRA Memorandum 7-11.doc | DOC document | |
| 626-23-201 Replace Chiller 2 Layout_Rev1.pdf | ||
| Switch Gear Location.pdf | ||
| Painting Standards.pdf | ||
| 36C24923B0023 0002.docx | DOCX document | |
| Pre-Bid Site Walk Sign In_Replace Chiller2_28SEP23.pdf | ||
| 36C24923B0023 0001.docx | DOCX document | |
| Calculation of Self Performance Work.pdf | ||
| VA Provided Chiller Cutsheets.pdf | ||
| UEI _ TAX ID.docx | DOCX document | |
| 626-24-201 Chiller 2 Specs.pdf | ||
| Sample ATS 13 VA Commissioning.pdf | ||
| RFI Form.docx | DOCX document | |
| DBA wage determination TN20230178 modification 4 last revised 06302023.pdf | ||
| General Conditions Breakout.xlsx | XLSX spreadsheet | |
| One Line Diagram 8-3-23.pdf | ||
| VA Chiller Details.pdf | ||
| 626-23-201 Replace Chiller 2 Layout.pdf | ||
| 36C24923B0023_1.docx | DOCX document | |
| Current 650 Ton Chiller 160-73-o2 Operating and Maintenance Manual.pdf | ||
| Sample Chiller Installation Checklist.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923B0023
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: 238220 Plumbing, Heating, and Air Conditioning Contractors.
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 .