S02 - Attachment_7_EMR_(MANDATORY)_DB_672-21-000_(1 Page).docx
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- Attached to
- Z2DA--Hurricane Recovery Project Phase 2
- Solicitation number
- 36C24822R0038
About this file
This document contains an attachment for a mandatory bidder evaluation form and information on a federal contract opportunity for hurricane recovery project phase 2 services. The attachment is a pre-award contractor evaluation form requesting company information, OSHA record details for the past three years including man hours and incident rates, copies of OSHA forms, NAICS code, safety program administrator, and experience modification rates.
The federal contract opportunity is a design-build project between $5-10 million to repair damages from hurricanes Irma and Maria in 2017 at the VA Caribbean Healthcare System in San Juan, Puerto Rico. The solicitation will be issued on December 29, 2021 via SAM.gov and is set aside for certified Service-Disabled Veteran-Owned Small Businesses. The point of contact is Rey Clemente and responses are due January 28, 2022 at 4:30pm Atlantic Time.
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Text version
ATTACHMENT: 7
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 |
| 2019 |
| 2020 |
| 2021 |
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 .