Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C24925R0061
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24924B0007. The form requires contractors to provide detailed safety and health information, including OSHA 300 Form data for 2019-2021, covering man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Contractors must attach OSHA 300 and 300a Forms and provide their six-digit NAICS Code, details about their safety and health program administrator, and their company's Insurance Experience Modification Rate (EMR).
This form is associated with a Department of Veterans Affairs solicitation (36C24925R0061) for a Design/Build project at the Tennessee Valley Healthcare System's Alvin C. York Campus. The project involves main entrance traffic improvements with a construction magnitude between $500,000 and $1,000,000. The solicitation is a 100% set-aside for Service-Disabled Veteran Owned Small Business (SDVOSB), with a NAICS Code of 237310 for Highway, Street, and Bridge Construction. Proposal submissions are due on 11/06/2025 at 1:00 PM CT, and electronic copies of signed SF 1442 Offer page and SF 24 Bid Bond are required.
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Other files
| File | Type | Posted |
|---|---|---|
| C28 Drawings_Sitework Concept 1.pdf | ||
| RFI_626A4-26-203-DB Main Entrance Traffic Improvements 02.pdf | ||
| P07_Wage Determination_2015-4647- 07-08-2025.pdf | ||
| 36C24925R0061_1.docx | DOCX document | |
| C28 Drawings_Sitework Concept 2.pdf | ||
| C27_Specifications.pdf | ||
| UEI _ TAX ID.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 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 .