Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- N059--621-26-100 - Replace Electrical Switchgear Bldg. 208 Federal contract opportunity
- Solicitation number
- 36C24925B0008
About this file
The file is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for a Department of Veterans Affairs Veterans Health Administration contract (Solicitation 36C24924B0007). The form requires contractors to provide detailed safety and environmental performance data, including OSHA 300 Forms documenting man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any OSHA violations for the years 2019-2021.
The related federal contract opportunity (Solicitation 36C24925B0008) involves replacing electrical switchgear and paralleling controls in Building 208 for Veterans Integrated Service Network 9. The project requires complete site preparation, demolition, and removal of existing structures, with a comprehensive replacement of medium voltage switchgear and controls. The period of performance is 365 days, and the base bid encompasses general construction, alterations, and necessary equipment removal and replacement.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Wage Determination_TN20250191 06-06-2025.pdf | ||
| 36C24925B0008_2.docx | DOCX document | |
| C28_621-26-100 Drawings.pdf | ||
| RFI Form.docx | DOCX document | |
| UEI _ TAX ID.docx | DOCX document | |
| C27_621-26-100 Specifications.pdf |
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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:
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 .