Contractor EMR Certification Form.docx
DOCX document 26 KB Posted
- Attached to
- Z1DA--621-23-104 - Relocate Police Dispatch
- Solicitation number
- 36C24926R0075
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0075, a police dispatch relocation project at the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form is a template designed to assess contractor safety performance and environmental compliance prior to contract award.
Contractors must complete the form by providing three years of occupational safety and health data (2024–2026) including total man hours, number of cases involving days away from work or restricted activity, DART rates, and counts of serious, willful, or repeat OSHA violations with explanations for any violations cited. Contractors are required to submit copies of their OSHA 300 and 300a Forms, identify their six-digit NAICS Code (236220 for Commercial and Institutional Building Construction), designate the administrator of their company's Safety and Health Program, and provide their Experience Modification Rate (EMR) from their company insurance carrier. The form functions as a pre-qualification assessment tool to evaluate contractor safety records and risk management capabilities before award of the police dispatch relocation contract.
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Other files
| File | Type | Posted |
|---|---|---|
| Amendment 0002_Police Dispatch 621-23-104_36C24926R0075.pdf | ||
| Relocate Police Dispatch - Pre-Bid Sign In Sheet.pdf | ||
| Amendment 0001_Police Dispatch 621-23-104_36C24926R0075.pdf | ||
| Police Dispatch RFIs and responses.xlsx | XLSX spreadsheet | |
| Calculation of Self Performed Work.xlsx | XLSX spreadsheet | |
| C28_621-23-104_Updated Specifications.pdf | ||
| 36C24926R0075_1.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| WAGE-RATES.docx | DOCX document | |
| UEI_TAX ID.docx | DOCX document | |
| C27_621-23-104_Updated Drawings.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24926R0075
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2024 |
| 2025 |
| 2026 |
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 .