Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Y1DA--Project# 614-20-109 Cooling Tower Replacement Federal contract opportunity
- Solicitation number
- 36C24925B0010
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925B0010, associated with a cooling tower replacement project for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requires contractors to provide comprehensive safety and environmental performance data, including OSHA 300 form details such as man hours, workplace injury cases, days away/restricted work rates, and OSHA violation history for the years 2023-2025.
Contractors must submit their six-digit NAICS code (238220), identify who administers their Safety and Health Program, and disclose their Company Insurance Experience Modification Rate (EMR). The form mandates attachment of OSHA 300 and 300a Forms, with an explanation required for any serious, willful, or repeat violations from the past three years. This documentation is part of the pre-award evaluation process for the Y1DA--Project# 614-20-109 Cooling Tower Replacement solicitation.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24925B0010 0002.docx | DOCX document | |
| 36C24925B0010 0001.docx | DOCX document | |
| C27_Drawings Cooling Tower.pdf | ||
| Wage Determination_TN20250200 06-06-2025.pdf | ||
| UEI _ TAX ID.docx | DOCX document | |
| C28_Specifications Cooling Tower.pdf | ||
| RFI Form.docx | DOCX document | |
| 36C24925B0010_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24925B0010
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
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: 238220
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 .