PER VHA DIRECTIVE 7715.docx

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Pharmacy Replacement Flooring due to Flooding
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36C26123R0088
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EMR RATE VHA DIRECTIVE 7715.docx Revision not stated Replacement of existing cooling tower: VA Northern California Health Care System (VANCHS) Martinez campus 150 Muir Road, Martinez, CA 94553
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PER VHA DIRECTIVE 7715 EMR.docx Revision not stated Menlo Park Replace Nurse Call Bldg. 331 and 360
PER VHA DIRECTIVE 7715 EMR.docx Revision not stated Menlo Park Replace Nurse Call Bldg. 331 and 360
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VHA Directive 7715 Safety and Health During Construction.pdf Revision not stated K063--Correct Physical Security Issues Construction | Project # 595-17-101 ALTOONA & LEBANON MATOC HOLDERS ONLY
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PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR):

Contractor Certification Regarding Project:

To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.

All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.

1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.

2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.

2019
2020
2021
2022

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)

Number of violations from EPA within the last 3 years. Please attach explanation for any violations.

Company’s Current Insurance Experience Modification Rate (EMR) = (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature:

Print Name:

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