36C25020B0003-015.docx

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Z1DA--Upgrade Anesthesia Pain Clinic 583-19-202
Solicitation number
36C25020B0003
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This document contains a federal contract solicitation and related contractor certification form. The upcoming solicitation from the Department of Veterans Affairs concerns upgrades to the Anesthesia Pain Clinic at the Richard L. Roudebush VA Medical Center. The solicitation will be issued on or around February 15, 2020 via SAM.gov and seeks construction services between $250,000 to $500,000 to provide general construction, alterations, electrical, mechanical, plumbing, HVAC, and other specialty work. The project is set aside 100% for Service-Disabled Veteran-Owned Small Businesses. The related contractor certification form requests information on recent OSHA violations, current insurance EMR rate, and signature for a pre-solicitation review. A site visit will also be scheduled prior to the closing of the solicitation.

36C25020B0003 Contractor Certification Regarding Safety and Environmental.docx

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Contractor Certification Regarding Project: 583-19-202

2016
2017
2018

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 violation could result in being determined non-responsible.)

Company’s Current Insurance Experience Modification Rate (EMR) = _____________ (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature: ______________________________________________

Typed Name: ______________________________________________________

Title: ______________________________________________________

File details come from the government source that posted it. Updated .