ContractorEMR_Certification.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24923B0016
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for replacing patient room doors at a Veterans Affairs medical center. The evaluation form requests contractors to provide man-hours and OSHA recordable incident data for the past three years, explanation for any serious violations, copies of OSHA forms 300 and 300A, their NAICS code for this work, who administers their safety program, and insurance experience modification rate. The related federal contract opportunity is a solicitation to provide all labor, materials, equipment, and supervision to replace doors and add access control in an intensive care unit at a Veterans Affairs hospital, including infection control requirements and phasing of the work. Only emailed bids will be accepted for this work by the specified due date.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923B0008
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: 238220
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 .