Contractor EMR Certification Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24922B0010
About this file
This document contains two statements of work for federal contracting opportunities to replace chillers at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The first opportunity involves replacing the operating room chiller under Project 621-19-125, and the second replaces the Building 204 chiller under Project 621-22-126. Both projects will be worked on concurrently over 300 calendar days. The solicitations are 100% set aside for service-disabled veteran-owned small businesses. The work includes demolishing and disposing of existing chillers, installing new approximately 80-ton and 120-ton chillers, related equipment and controls. Bids are due by the date specified in block 13A of the SF1442 form. The selected contractor must meet all safety, environmental, insurance and security requirements, and prevailing wage standards apply.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation:
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2015 |
| 2016 |
| 2017 |
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 .