Contractor_EMR_Certification_Form.pdf
PDF 187 KB Posted
- Attached to
- Project_621-22-133 - Bldg. 200 Wing B2 Renovate VAV Controls Federal contract opportunity
- Solicitation number
- 36C24922B0015
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 renovation of variable air volume controls at a Department of Veterans Affairs medical facility.
The evaluation form requests contact information and safety data from the past three years, including total man hours, OSHA recordable incidents, injury rates, and violations. It also asks for the company's NAICS code, safety program administrator, and experience modification rate. The related federal contract opportunity is solicitation number 36C24922B0015 to renovate 26 variable air volume controls and add a new box at building 200 of a Veterans Health Administration facility. The work includes controls, reheat, and direct digital controls per the statement of work, drawings, and specifications.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment_0002-36C24922B0015-QA_final.pdf | ||
| Amendment_0001-36C24922B0015-QA.pdf | ||
| SOLICITATION-36C24922B0015-IFB_RenovateVAVcontrols_Bld200.pdf | ||
| Drawing Attachment - 4 - SITE MAP Update 5.pdf | ||
| Specification_Rev2- 621-22-133 Bldg 200 Wing B2 Renovate VAV Controls.pdf | ||
| Drawings Attachment-6 - Bldg 200 Section B and C-Heating_WaterPiping.pdf | ||
| Drawings Attachment -2 - Bldg 200 Wing B2 Electrical.pdf | ||
| Drawings Attachment -1 - Overview-Bldg 200 Wing B2-VAV_locations.pdf | ||
| Drawings Attachment-5 - Mechanical Building 200 Section B and C Second Floor.pdf | ||
| Drawings Attachment -3- VAV Box Schedule.pdf | ||
| Davis_BaconAct-POSTER.pdf | ||
| DB_WageDetermination-TN20210111_2-25-2022.pdf | ||
| RFI_Form-Project_621-22-133.pdf |
Show all 13
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0015
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: __________________________________
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 .