Contractor EMR Certification Form.pdf
PDF 86 KB Posted
- Solicitation number
- 36C24921R0010
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity to renovate Building #34 at a Veterans Affairs facility to correct deficiencies. The evaluation form requests contact information and safety data from the past three years, including total man hours, OSHA recordable incidents, days away from work rates, and serious violations. It also asks for the company's North American Industry Classification System code, safety program administrator, and experience modification rate. The related federal contract opportunity is solicited by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 to renovate Building #34 and correct deficiencies as identified in the Facility Condition Assessment.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24921R0010
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2017 2018 2019
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 .