Contractor EMR Certification Form.pdf
PDF 141 KB Posted
- Solicitation number
- 36C24922B0024
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for the solicitation number 36C24922B0024 to replace flooring and abatement at a Veterans Affairs medical center in Nashville. The form requests contact information and safety data including OSHA recordable incidents, rates, violations, and insurance experience modification rate. It also asks for the company's six-digit NAICS code and information on its safety and health program administrator. Attached documents include the bidder's OSHA 300 and 300A forms from the past three years.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24922B0024 0002.pdf | ||
| WD TN20220178 6-17-22.pdf | ||
| 36C24922B0024 0001.docx | DOCX document | |
| Specs 626-22-501_Flooring and Abatement_.pdf | ||
| Header - List of Attachments.docx | DOCX document | |
| WD 20220178 5-6-22.pdf | ||
| Calculation of Self Performance Work.pdf | ||
| RFI Form - Replace flooring and abatement.pdf | ||
| Drawings 626-22-501 Flooring and Abatement_.pdf | ||
| 36C24922B0024_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24922B0024 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): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .