S02 - EMR_(Fill-In Mandatory)_(1 Page).pdf
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- Solicitation number
- 36C24822R0155
About this file
This document provides details for a federal design-build contract opportunity for HVAC installation services. The Department of Veterans Affairs seeks proposals to design and construct a new backup HVAC unit at the San Juan VA Medical Center in Puerto Rico. Interested parties must be certified as Service-Disabled Veteran-Owned Small Businesses. Proposals are due by August 1, 2022. The contract value is estimated between $100,000 and $250,000. The selected contractor will be responsible for all design, engineering, construction, and commissioning of a new air handling unit and associated mechanical, electrical and controls systems to serve as redundant capacity for an existing unit. The work must be completed within 365 calendar days of the notice to proceed and adhere to all applicable construction standards and codes.
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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): _____________
FILL-IN MANDATORY AND PROVIDE SUPPORTING DOCUMENTATION MANDATORY.
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