Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24924B0004
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a federal construction contract opportunity with the Department of Veterans Affairs. The form requests contact information and safety data from the past three years, including total man hours, OSHA recordable incidents, days away from work rates, and serious violations. It also asks for the contractor's NAICS code for commercial and institutional building construction, who administers their safety program, and insurance experience modification rate. The related federal contract opportunity is for underground hallways and interior renovations on the fourth floor of the Tennessee Valley Healthcare System Nashville Veterans Affairs Medical Center.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924B0004
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2021 |
| 2022 |
| 2023 |
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 Commercial and Institutional Building Construction.
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 .