EMR Certification Form.pdf
PDF 141 KB Posted
- Attached to
- Z1DA--Project 626A4-16-105 - Replace Flooring and Abatement Federal contract opportunity
- Solicitation number
- 36C24922B0022
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for Solicitation 36C24922B0022 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requests contact information and safety data from 2018 to 2020 including man hours, OSHA recordable incidents, days away from work or job transfer rates, and serious violations. It also requests the company's six-digit NAICS code, safety program administrator, and experience modification rate as well as copies of the past three years of OSHA Forms 300 and 300A. The related federal contract opportunity is for Project 626A4-16-105 to replace flooring and conduct abatement work at a Veterans Affairs facility.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24922B0022 0001.docx | DOCX document | |
| Header - List of Attachments.docx | DOCX document | |
| 36C24922B0022_1.docx | DOCX document | |
| Calculation of Self Performance Work.pdf | ||
| RFI Form - Replace flooring and abatement.pdf | ||
| WD TN20220100 2-25-2022.pdf | ||
| 626A4-22-105 Replace Flooring and Abatement Drawings revised.pdf | ||
| 626A4-16-105_Replace_Flooring_And_Abatement_Specs revised.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: 36C24922B0022 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: __________________________________
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 .