Attachment 2 - EMR.pdf
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- Solicitation number
- 36C24824R0093
About this file
This document is an EMR (Experience Modification Rate) form for bidders/offerors to complete and submit with their proposal. The form requires the company to provide information on their OSHA 300 forms, including the number of man-hours, days away, restricted, or transferred (DART) rate, and any OSHA violations within the last 3 years. The company must also provide their 6-digit NAICS code, who administers their safety and health program, and their EMR for the past 3 years (an EMR greater than 1.0 disqualifies the contractor).
This EMR form is related to a federal contract opportunity for the "Installation of New Chillers at Buildings 7 & 10" at the Miami VA Medical Center. The Department of Veterans Affairs is seeking Design-Build construction services for this project, which involves installing independent air-cooled chillers in Buildings 7 and 10 to provide dedicated cooling and enhance the overall resilience and redundancy of the campus's chilled water system. Phase One Proposals are due on 04/10/2024 at 11:00 am EST, and Phase One RFIs are due on 03/27/2024 at 11:00 am EST.
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE AND 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 2021 2022 2023
Number of man hours (job site and office)
The number of cases involving days away from work, restricted activity, or both (Columns 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).
The number of serious, willful, or repeat violations from OSHA within the last 3 years.
Please attach an 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 .