Contractor EMR Certification Form.docx
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- Solicitation number
- 36C24924R0098
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation 36C24924R0098 for the EHRM Infrastructure Upgrade Albion Clinic project.
The form requires the contractor to provide information on their OSHA 300 forms, including man-hours, days away/restricted/transferred cases, DART rates, and any OSHA violations in the last 3 years. The contractor must also provide their 6-digit NAICS code, who administers their safety program, and their Insurance Experience Modification Rate (EMR). The solicitation is for $100,000 to $250,000 of work to furnish labor, materials, and equipment for site preparation and building operations at the Tennessee Valley Healthcare System Albion Street VA Clinic in Nashville, TN. It is a Service-Disabled Veteran Owned Small Business (SDVOSB) set-aside. Proposal submissions are due via email, and there will be one site visit scheduled.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924R0098
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 .