Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24922B0016
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for replacing SPS flooring. The form requests information on the contractor's man hours, OSHA recordable incidents, DART rates, OSHA violations, and insurance EMR over the past three years. It also asks for the contractor's NAICS code and who administers their safety program. The related federal contract opportunity is solicitation number 36C24922B0016 from the Department of Veterans Affairs to furnish all labor, materials, and equipment to replace SPS flooring at the James H. Quillen VA Medical Center in Mount Home, Tennessee.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24922B0016 0005.docx | DOCX document | |
| 36C24922B0016 0004.docx | DOCX document | |
| 090516 subsurface prep for floors.pdf | ||
| Government Answers to Industry Questions.pdf | ||
| 15SANITARYSYS.pdf | ||
| 36C24922B0016 0003.docx | DOCX document | |
| 36C24922B0016 0002.docx | DOCX document | |
| 36C24922B0016 0001.docx | DOCX document | |
| Pre-bid Site Visit 6-1-2022 Sign-in Sheet.pdf | ||
| Specifications.pdf | ||
| RFI Form - Mt. Home SPS Flooring.docx | DOCX document | |
| 36C24922B0016_1.docx | DOCX document | |
| Calculation of Self Performed Work.docx | DOCX document | |
| StonblendGSIProduct Data Template kat 6-4-19.pdf | ||
| Drawings 621-22-124 Project Area.pdf | ||
| GD TN20220191 05-06-2022 Washington County TN.pdf | ||
| STERIS Mobile SPD Deployment Guide Updated 3-26-2020.pdf | ||
| VHA Supplemental Contract Requirements for Combatting COVID-19 Updated 12-16-2021.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 36C24922B0016
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: 238330
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 .