S02 - ATTACHMENT 4 - EMR (1 PAGE).docx
DOCX document 14 KB Posted
- Attached to
- Z1DA-- (PROJ: 546-CSI-125) D/B Replace LINAC (Linear Accelerator) Federal contract opportunity
- Solicitation number
- 36C24822R0126
About this file
This document contains an EMR form for bidders to complete and submit with proposals for a federal contract opportunity with the Department of Veterans Affairs. The form requests the bidder's company name, address, contact information, NAICS code for the acquisition, administrator of its safety and health program, and EMR rates for the past three years. It also requires bidders to provide OSHA 300 and 300a forms from 2019 to 2021 with man hours, cases involving days away from work or restricted activity, DART rates, and serious, willful, or repeat violations. Bidders with an EMR over 1.0 or with certain OSHA violations in the past three years will be disqualified.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| S02 - ATTACHMENT 6 - SPECIALIZED EXPERIENCE FROM.pdf | ||
| 36C24822R0126_2.docx | DOCX document | |
| S02 - ATTACHMENT 5- PAST PERFORMANCE QUESTIONNAIRE.pdf | ||
| S02 ATTACHMENT 3- PRICE MATRIX.xlsx | XLSX spreadsheet | |
| Attachment 1 Site Plan 09- CSI-125 Site and Floor Plan.pdf | ||
| Attachment 2 - Wage Determination.pdf | ||
| 36C24822R0126.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 .