SAFETY - ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE -Attachment 3.pdf
PDF 193 KB Posted
- Attached to
- Z1DA--36C26126R0052 Replace Buildings 911 and 98 - Fire and Security Alarms Project # 612A4-26-051
- Solicitation number
- 36C26126R0052
About this file
This is a contractor certification template based on VHA Directive 7715 (06 April 2017) establishing safety and environmental record requirements for federal contracts. To be eligible for consideration and award, contractors must have no more than three serious OSHA or EPA violations, or one repeat violation, or one willful violation within the past three years, and must maintain an Experience Modification Rate (EMR) equal to or less than 1.0.
All offerors are required to submit two compliance documents with their proposals. First, contractors must provide a self-certification on company letterhead confirming they meet the violation thresholds outlined above. Second, offerors must submit current EMR information obtained from their insurance carrier on the carrier's letterhead; if an offeror's EMR exceeds 1.0, they must also submit a written explanation from the insurance carrier detailing reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below. The template includes a table for reporting the number of serious, willful, or repeat OSHA violations and EPA violations by year (2023, 2024, 2025) with instructions to attach explanations for any violations reported. The document concludes with signature and name fields for authorized company representatives executing the certification.
View the file
Other files
Show all 28
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
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 Offerors’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.
2023 2024 2025
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: _________________________________________________
File details come from the government source that posted it. Updated .