S02 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C25020B0059
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for correcting deficiencies at a Veterans Administration medical center. The evaluation form requests safety and environmental records from the past three years, including OSHA forms, violation details, and insurance experience modification rate. The related opportunity is a 100% set-aside for small businesses with a preference for service-disabled veteran-owned small businesses. The project scope involves correcting interior deficiencies and has a magnitude between $500,000 and $1,000,000. The NAICS code is 238220 for commercial and institutional building construction. The solicitation number is 36C25020B0059 and will be posted on August 10, 2020. The duration shall not exceed 180 days from notice to proceed. Bonds will be required.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 539-20-211:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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 .