Contractor EMR Certification Form.pdf
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- Solicitation number
- 36C24921R0141
About this file
This document contains a pre-award contractor safety evaluation form and details of a federal solicitation to upgrade a nurse call system.
The evaluation form requests contractors to provide safety information including OSHA recordable incident rates for the past three years, explanations for any serious violations, copies of OSHA forms, NAICS code, safety program administrator, and experience modification rate. The related solicitation is for upgrading the nurse call system at the Alvin C. York VA Medical Center in Murfreesboro, TN and Nashville, TN. The upgrade requires general construction, electrical work and all associated labor, materials and equipment. The solicitation is issued by the Department of Veterans Affairs Veterans Health Administration VISN 9. Contractors must meet the safety evaluation requirements to be considered for this work to improve patient care systems at two VA medical facilities.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24921R0141
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020
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): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .