19C. AFFIRMATION_OF_NIH_CONTRACTOR_SAFETY_DELIVERABLES_2017.2.pdf

AFFIRMATION OF NIH CONTRACTOR SAFETY DELIVERABLES

The National Institutes of Health is committed to providing a safe environment for its employees, guests, and patients. At a minimum the contractor and its subcontractors shall comply with applicable Occupational Safety and Health Administration (OSHA) regulations. Construction, renovation, alteration and maintenance services must adhere to the provisions of the US Army Corps of Engineers Safety and Health Manual 385-1-1 (EM 385-1-1).

CONTRACTOR NAME:

enter text.

CONTRACT NUMBER :

enter text.

Work Request No:

enter text.

Contract Dates:

Start Date: Date

End Date: Date

Description of Contract Scope of Work:

Click here to enter text.

Contract Type: ☐ Construction/Renovation ☐ Maintenance ☐Service

☐ Other:_______________________________________

Will sub-contractors provide on-site services to support the contract? ☐ Yes ☐ No

Anticipated number of employees (prime and subcontractors) assigned to the contract: Click here to enter text.

I certify the following safety deliverables have been submitted to the Contracting Officer, Contracting Officer’s Representative, and Division of Occupational Health and Safety (DOHS) (safety@nih.gov) :

☐ Copies of appropriate OSHA 10-hour training certification (i.e. general industry or construction) for on-site personnel.

☐ The Contractor Safety Assessment Program certification (https://www.constructsecure.com/nih ) for contractor and each sub-contractor.

☐ The site specific accident prevention plan completed in accordance with the Army Corps of Engineers Safety Manual.

☐ The curriculum vitae (a.k.a. resume) of the assigned qualified safety officer, hired by the contractor, to oversee the contract operations.

Services authorized under this contract will not commence without first submitting for review each of the safety deliverables. Safety deliverables shall be updated to reflect changes in personnel, work environment, or services. Failure to comply with the contract’s safety clauses will result in the issuance of a cure notice. A termination for cause may be issued for subsequent violations of the contract’s safety clauses.

PERSON EXECUTING CONSENT (Signature) *

BY DATE:

Contractor Safety Officer (Signature)

BY DATE:

CONSENT (Signature)

TYPED NAME AND TITLE TYPED NAME AND TITLE TITLE

* The Principal or authorized representative shall execute. Phone: email:

Upon completion, submit this form to the Contracting Officer and to DOHS: safety@nih.gov.

The form must be submitted prior to commencing work, unless exempted by the Contracting Office.

mailto:safety@nih.gov https://www.constructsecure.com/nih mailto:safety@nih.gov