S02 - Attachment_9_EMR_(FILL-IN IS MANDATORY)_(1 Page).pdf
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- Attached to
- Y1LB--Replace AMA Bridge
- Solicitation number
- 36C24823R0017
About this file
This document contains a pre-solicitation notice for design-build services to replace a pedestrian bridge at the VA Caribbean Healthcare System in San Juan, Puerto Rico. The Department of Veterans Affairs is seeking to completely replace an existing pedestrian bridge between an AMA parking lot and VA facilities with a new structure. The contractor will be responsible for design, construction, fencing around the work area during construction, and removal and disposal of the existing bridge. The project value is estimated between $1,000,000 to $2,000,000. The solicitation is scheduled for issuance on November 25, 2022. The pre-solicitation notice provides a point of contact and states the requirement is set aside for Service-Disabled Veteran-Owned Small Businesses. Interested SDVOSBs must be registered in SAM.gov and verified in the VIP database by the response date of January 3, 2023 to be eligible to compete.
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Text version
ATTACHMENT: 9
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 .