Contractor EMR Certification Form 2020.pdf
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- Solicitation number
- 36C24921B0004
About this file
This document contains a pre-solicitation notice and related contractor experience modification rate form for an upcoming construction services solicitation. The Department of Veterans Affairs will be soliciting bids on or around January 7, 2021 for renovations to Building 160 at the James H. Quillen VAMC in Mountain Home, Tennessee. The project magnitude is estimated between $2-5 million, with a 365 day period of performance. The NAICS code is 236220 and it is set aside 100% for Service-Disabled Veteran-Owned Small Businesses. The solicitation will require OSHA forms, safety plans, and insurance experience modification rates be provided. Bidders must also be verified as SDVOSBs by the VA Center for Veterans Enterprise by the time of bid submission.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C24921B0004 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): ______ http://www.osha.gov/pls/publications/publication.html
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