Attachment 6 -(Exhibit C) EMR.docx
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- Solicitation number
- 36C24821R0139
About this file
This document contains a pre-solicitation notice and Exhibit C form for a construction project opportunity with the Department of Veterans Affairs. The pre-solicitation notice describes a project to expand and renovate the Cardiothoracic Intensive Care Unit at the Malcolm Randall VA Medical Center in Gainesville, Florida to increase capacity, improve functionality and patient privacy. The project includes bid alternates to deduct switchable privacy glass and replace it with either ceiling-mounted curtain tracks or clear tempered glass. The estimated contract value is between $1-5 million. The NAICS code for this procurement is 236220. Interested parties should register at beta.SAM.gov as the solicitation and all official documents will be available there on or around July 28, 2021. Exhibit C is a form for bidders to complete and submit with their proposal providing safety history information such as OSHA recordable incidents, experience modification rates, and safety program administration details.
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
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. (Four serious, one repeat, or one willful disqualifies the contractor.)
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 your 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) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________
File details come from the government source that posted it. Updated .