Contractor EMR Certification Form.docx
DOCX document 18 KB Posted
- Solicitation number
- 36C24926R0057
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for solicitation 36C24926R0017 related to the renovation of Building 204 Cath Lab II at the James H. Quillen VA Medical Center in Mountain Home (Johnson City), Tennessee. The form requests contractor safety and environmental performance data across three years (2023, 2024, and 2025) and requires submission of OSHA 300 and 300a Forms documenting man hours, cases involving days away from work or restricted activity, DART rates, and any serious, willful, or repeat OSHA violations within the preceding three years with explanations for violations.
Contractors must identify their six-digit NAICS code (236220 – Commercial and Institutional Building Construction applies to this acquisition), name the administrator of their company's Safety and Health Program, and provide their current Insurance Experience Modification Rate (EMR). This evaluation form is a pre-award requirement used by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 to assess contractor safety records and compliance history prior to contract award.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24926R0017
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 your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220 – Commercial and Institutional Building Construction
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 .