S02 - ATTACHMENT 3 - EMR (1 PAGE).docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--D/B - (Pro:j 675-22-812) LAKE NONA SIGNAGE
- Solicitation number
- 36C24822R0124
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for signage at Lake Nona in Orlando, Florida. The evaluation form requests company information including North American Industry Classification System code, OSHA recordable incident rates for the past three years, proof of workers' compensation insurance rates, and safety program administration. Bidders must have an experience modification rate of 1.0 or below. The related solicitation is for a design-build project to install signage directing visitors to various facilities. The opportunity is open to all responsible sources and proposals are due on April 15, 2022. The contract is expected to be awarded by May 2022 to be completed by January 2023.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24822R0124 0004_1.docx | DOCX document | |
| 36C24822R0124 0003_1.docx | DOCX document | |
| 36C24822R0124 0002_1.docx | DOCX document | |
| 36C24822R0124 0001_1.docx | DOCX document | |
| S02 ATTACHMENT 1 WD.txt | TXT text file | |
| 36C24822R0124_2.docx | DOCX document | |
| S02 - ATTACHMENT 5 - SPECIALIZED EXPERIENCE FROM.pdf | ||
| S02 ATTACHMENT 2- PRICE MATRIX.xlsx | XLSX spreadsheet | |
| S02 - ATTACHMENT 4- PAST PERFORMANCE QUESTIONNAIRE.pdf | ||
| 36C24822R0124.docx | DOCX document |
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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 |
| 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 .