Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Z1DZ--Project# 626-22-201 Upgrade Oxygen Federal contract opportunity
- Solicitation number
- 36C24924B0007
About this file
This document is a pre-award contractor safety evaluation form for the solicitation to upgrade oxygen systems at a Veterans Affairs medical facility. The form requests safety record information over the past three years, including total man hours, OSHA-recordable incidents, and days away from work rates. It also asks for the North American Industry Classification code, details on the company's safety program administrator, and experience modification rate for insurance purposes. The related federal contract opportunity is for project number 626-22-201 to upgrade oxygen systems under solicitation number 36C24924B0007 issued by the Department of Veterans Affairs Veterans Health Administration VISN 9. Contractors are required to submit this safety evaluation form and supporting documentation as part of the pre-award evaluation process for the oxygen system upgrade work at the VA medical center.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24924B0007 0002.docx | DOCX document | |
| 36C24924B0007 0001.docx | DOCX document | |
| CALCULATION OF SELF PERFORMED WORK.docx | DOCX document | |
| C28_ Specifications_626-22-201 Upgrade.pdf | ||
| WD_TN20230178 10-13-2023.pdf | ||
| UEI _ TAX ID.docx | DOCX document | |
| 36C24924B0007_1.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| C27_Drawings_626-22-201 Upgrade.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924B0007
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 .