Contractor EMR Certification Form.pdf
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- Attached to
- Y1DZ--Renovate Basement, Building 1 610A4-19-104
- Solicitation number
- 36C25021B0018
About this file
This document contains a solicitation for a construction renovation project and a contractor safety evaluation form. The solicitation seeks bids to renovate the basement of Building 1 at the VA Northern Indiana Health Care System campus in Fort Wayne, Indiana over three phases to modernize space for various medical, administrative, and operational functions. Phase I is scheduled for 300 days, Phase II for 210 days, and Phase III for 270 days. The work involves renovating rooms and corridors, and removing asbestos and lead paint, in accordance with provided design documents and OSHA guidelines. Bidders must have experience modification rates and attach safety records from the past three years, including OSHA Forms 300 and 300A. The solicitation will be posted on SAM.gov on March 11, 2021 and is issued by the Department of the Air Force Materiel Command Installation Contracting Agency to improve operations and patient safety at the Fort Wayne VA facility.
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Text version
Contractor Safety and Environmental Record Evaluation Form
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: 236220
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 .