Contractor EMR Certification Form.pdf
PDF 137 KB Posted
- Solicitation number
- 36C24921R0086
About this file
This document contains a pre-award contractor safety evaluation form and information on a related federal contract opportunity for construction services. The pre-award form requests a contractor's OSHA 300 forms from 2017 to 2019 with man hours, injury cases, and DART rates. It also requests the contractor's NAICS code, safety program administrator, and experience modification rate. The related federal opportunity is a solicitation from the Department of Veterans Affairs for construction services to correct mechanical system deficiencies at a VA medical center. The work includes general construction and alterations with an estimate between $1-3 million. The requirement is a 100% SDVOSB set-aside and offers are due by June 12, 2020.
View the file
Other files
Show 40 more
Latest 50 of 55 listed here. See the rest on GovTribe.
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24921R0086
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 .