Amendment 0002 - Contractor EMR Certification Form.docx
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- Solicitation number
- 36C24922B0001
About this file
This document contains a pre-award contractor experience modification rate form and information on a related federal contract opportunity. The form seeks information from potential awardees on the solicitation for Project 603-20-202 to Restore AHU-10 System at the VA medical center in Louisville, Kentucky. It requests details on the contractor's OSHA 300 forms, experience modification rate, NAICS code, and safety program administration for the past three years. Specifically, the contractor is asked to provide man hours, injury cases, DART rate, any OSHA violations, copies of 2019 OSHA 300 forms, the six-digit NAICS code for this acquisition, and the name and title of the person administering their safety and health program. The related opportunity is for a contractor to prepare the site, including demolition and removal of existing structures, and furnish labor and materials to perform the work required by drawings and specifications to restore the AHU-10 system in operating rooms 5 through 7. The contracting agency is the Department of Veterans Affairs Veterans Health Administration VISN 9.
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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 36C24922B0001 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 |
| 2018 |
| 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.
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 .