Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24922B0023
About this file
This document contains a pre-award contractor safety evaluation form and information on a related federal contract opportunity for emergency power installation. The evaluation form requests a contractor's OSHA 300 forms and injury rates for the past three years, explanations for any OSHA violations, copies of the OSHA 300 and 300A forms, and the contractor's six-digit NAICS code. It also asks for the name of the person who administers the company's safety program and the contractor's insurance experience modification rate. The related federal contract opportunity is solicitation number 36C24922B0023 from the Department of Veterans Affairs to install emergency power to Building 20 at a price to be determined with responses due by an unspecified date.
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Other files
| File | Type | Posted |
|---|---|---|
| COVID Language_Updated 12-14-2021.docx | DOCX document | |
| DUNS _ TAX ID.docx | DOCX document | |
| 36C24922B0023_1.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| Wage Determinmation MTH 05-06-22.pdf | ||
| Drawings 621-22-116 Install Emergency Power to Building 20.pdf | ||
| Specs 621-22-116 Install Emergency Power to Building 20.pdf |
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0018
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: 238210
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 .