Contractor EMR Certification Form.pdf
PDF 139 KB Posted
- Solicitation number
- 36C24923B0012
About this file
This solicitation document requests bids for a renovation project at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The project involves renovating the domiciliary recreation room in Building 160, including replacing the building's roof. The solicitation specifies a 100% set-aside for Service-Disabled Veteran Owned Small Businesses. The performance period is 180 calendar days from notice to proceed. Bids are due on February 1, 2022 and the bid opening will occur via Microsoft Teams on that date at 1:00 PM Central Time. The document outlines contractor experience, insurance, and safety requirements, and provides standard clauses on privacy, records management, and contractor performance evaluations.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24923B0012 0002.docx | DOCX document | |
| AE601 Rev 1 June 23.2023.pdf | ||
| 36C24923B0012 0001.docx | DOCX document | |
| AE401 Rev 1 June 23.2023.pdf | ||
| RFI Form - Renovate Domiciliary.pdf | ||
| Header - List of Attachments.txt | TXT text file | |
| 36C24923B0012_1.docx | DOCX document | |
| Specifications 621-23-107 15 May 23.pdf | ||
| DUNS _ TAX ID.pdf | ||
| 621-23-107 Dwgs 5.15.2023.pdf | ||
| WD TN20230191 5-12-23.pdf | ||
| General Conditions Breakout.xlsx | XLSX spreadsheet | |
| S02 - CALCULATION OF SELF PERFORMED WORK.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:
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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 .