Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Y1NA--621-21-107 Replace Upgrade Diesel Storage Tanks Federal contract opportunity
- Solicitation number
- 36C24924B0001
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity to replace and upgrade diesel storage tanks. The evaluation form requests company information and safety data including number of man hours, OSHA recordable incidents, injury rates, violations, and insurance experience modification rate. It also requires attaching OSHA forms and providing the company's NAICS code. The related federal contract opportunity is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 to replace and upgrade diesel storage tanks under solicitation number 36C24924B0001. The opportunity type is a solicitation and no further details are provided regarding response dates, pricing terms, or other requirements.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Pre-Bid Sign-In Sheet_621-21-107_36C24924B0001.pdf | ||
| Question Answers_621-21-107 -Replace Upgrade Diesel Storage Tanks.pdf | ||
| 36C24924B0001 0003.docx | DOCX document | |
| Addtional Question Answers_621-21-107 -Replace Upgrade Diesel Storage Tanks.pdf | ||
| 36C24924B0001 0002.docx | DOCX document | |
| P07_Wage Determination_TN20230191 05-12-2023.pdf | ||
| TS02 - CALCULATION OF SELF PERFORMED WORK.docx | DOCX document | |
| C28_Specs_621-24-1-5616-0001_621-21-107 100.pdf | ||
| 36C24924B0001_1.docx | DOCX document | |
| UEI _ TAX ID.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| C27_Drawings_621-24-1-5616-0001_621-21-107 100.pdf |
Show all 12
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0018
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
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: 238210
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 .