Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C24920B0003
About this file
This document is a pre-award contractor experience modification rate form required as part of an offer for solicitation 36C24920B0003 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requests safety and health information over the past three years including man hours, OSHA recordable incidents, days away from work rates, and any serious violations. Applicants must provide their six-digit NAICS code, safety program administrator name and title, and insurance EMR. The related federal contract opportunity is for project number 614-19-102 concerning the renovation of building 7 for a spinal cord injury rehabilitation area at a price to be determined.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24920B0003 0007.docx | DOCX document | |
| 36C24920B0003 0006.docx | DOCX document | |
| 36C24920B0003 0005.docx | DOCX document | |
| 36C24920B0003 0004.docx | DOCX document | |
| Amendent_SPECS.pdf | ||
| Amend Rpt 0001.pdf | ||
| Amendment_DRAWINGS.pdf | ||
| 36C24920B0003 0003.docx | DOCX document | |
| RFI Form - Renovate Bldg. 7 SCI Rehab Area.docx | DOCX document | |
| 36C24920B0003 0002.docx | DOCX document | |
| 36C24920B0003 0001.docx | DOCX document | |
| Drawings 614-19-102.pdf | ||
| Electric-Telecom Drawings.pdf | ||
| 36C24920B0003_1.docx | DOCX document | |
| Addendum G-101.pdf | ||
| Architectural Drawings 2.pdf | ||
| Wage Determination - Shelby County.pdf | ||
| Specifications.pdf | ||
| Architectural Drawings 1.pdf | ||
| Mechanical Drawings.pdf | ||
| Fire-Plumbing Drawings.pdf | ||
| General Drawings.pdf |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C24920B0003 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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.
2. Please attach copies of the following documents: 2019 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .