Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Z2DZ--36C249-21-AP-3989 - Project 621-20-101 Correct FCA Deficiencies w Historical Chapel Building 13
- Solicitation number
- 36C24921B0017
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for construction services. The pre-award form requests company and safety information including OSHA recordables, violations, NAICS code, and experience modification rate. The federal contract opportunity is to correct deficiencies at the James H. Quillen VA Medical Center's Historical Chapel building, including selective demolition, abatement, restoration, and new construction of interior and exterior features. The estimated value is between $2 million and $5 million. The solicitation will be issued on October 15, 2021 and close on November 16, 2021. This is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses. The NAICS code is 236220 and size standard is $39.5 million. The contracting agency is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24921B0017
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
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 .