S02 Attachment D_Contractor Certification RE Safety and EMR 640-22-112.docx
DOCX document 15 KB Posted
- Attached to
- VAPAHCS Electronic Cylinder Rekey (9 Facilities) Federal contract opportunity
- Solicitation number
- 36C26123R0054
About this file
This document contains a contractor certification regarding safety and environmental records for a federal solicitation from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21. The solicitation is for electronic cylinder rekey services at nine Veterans Affairs Palo Alto Health Care System facilities. To be eligible for consideration, contractors must have no more than three serious or one repeat or one willful Occupational Safety and Health Administration or Environmental Protection Agency violations in the past three years, and an experience modification rate of 1.0 or less according to their insurance carrier. Offerors must submit certifications of their safety and environmental records on company letterhead, as well as documentation of their current experience modification rate on insurance carrier letterhead.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C26123R0054 0002.pdf | ||
| 36C26123R0054 0001.pdf | ||
| S02 Attachment C_Price Breakdown 640-22-112.xlsx | XLSX spreadsheet | |
| Key Personnel Attachment for Evaluation 36C26123R0054.docx | DOCX document | |
| 640-22-112 - SOW Attachment A - Specifications.pdf | ||
| CA20230018 4.21.2023.pdf | ||
| S02 - RFI Form - 36C26123R0054 640-22-112.docx | DOCX document | |
| S02 - Attachment B PPQ 36C26123R0054.rtf | RTF text file | |
| 36C26123R0054 Electronic Cylinder Rekey 1442.pdf |
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Text version
ATTACHMENT D
CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL
Contractor Certification Regarding Project: 36C26123R0054 - VA Palo Alto - Electronic Cylinder Rekey, Project # 640-22-112 PER VHA DIRECTIVE 7715 (06 April 2017): SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR): 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) within 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 bid/proposal:
SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the Offeror has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) within the past three years. Include the following table and signature block.
| 2020 |
| 2021 |
| 2022 |
Number of serious, willful, or repeat violations from OSHA within the last 3 years.
Number of serious, willful, or repeat violations from EPA within the last 3 years
Signature: ______________________________________________ Typed Name: ______________________________________________________ Title: ______________________________________________________
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.
Contractor’s Current Insurance Experience Modification Rate (EMR) = _____________ (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)
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