VA263-17-R-1144-006.docx

VHA Construction Safety Directive 2011-36

Offerors Must Submit OSHA, EPA and EMR Information with Proposals

VHA Directive 2011-036 is incorporated into this solicitation by reference.

All offerors shall submit the following information pertaining to their past Safety and Environmental record. The information shall contain, at a minimum, a certification that the bidder/offeror 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.

All Bidders/Offerors shall submit information regarding their current Experience Modification Rate (EMR). This information shall be obtained from the bidder’s/offeror’s insurance company and be furnished on the insurance carrier’s letterhead, verifying that the contractor’s current Experience Modification Rate (EMR) is equal to or less than 1.0.

Self-insured contractors or other contractors that cannot provide their EMR rating on insurance letterhead must obtain a rating from the National Council on Compensation Insurance, Inc. (NCCI) by completing/submitting form ERM-6 and providing the rating on letterhead from NCCI. Note: Self-insured contractors or other contractors that cannot provide EMR rating on insurance letterhead from the states or territories of CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR shall obtain their EMR rating from their state run worker’s compensation insurance rating bureau.

This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for obtaining this information from their prospective subcontractors.

Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to solicitation:

Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

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: __________________________________

3. Who administers your company’s Safety and Health Program? ____________________________

4. Company’s Insurance Experience Modification Rate (EMR): ____________________________