Attachment IV - Contractor EMR Certification Form 610A4-21-205.docx

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Attached to
Z1DA--Upgrade Lobby Restrooms 610A4-21-105
Solicitation number
36C25022B0024
Issued by

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This document provides details for an upcoming construction project solicitation for the Department of Veterans Affairs. The solicitation will require upgrading lobby restrooms at the Northern Indiana Health Care System located in Fort Wayne, Indiana. The project scope includes updating existing restrooms and creating two new restrooms designed to meet ABAAS accessibility standards, and will be conducted in phases to mitigate interruptions. The NAICS code for this requirement is 238220 for plumbing, heating, and air conditioning contractors for renovation projects up to $16.5 million. The estimated value is between $2-5 million. The RFP or IFB will be issued on March 28, 2022 via Beta.SAM.gov. A site visit will also be scheduled. This project is 100% set aside for Service-Disabled Veteran-Owned Small Businesses. Offerors must provide safety or environmental violation details and have an experience modification rate of 1.0 or less before award.

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Other files

File Type Posted
36C25022B0024 0001 (2).pdf PDF
610A-21-105 Upgrade Lobby Restroom Pre-bid Site Visit Sign in.pdf PDF
36C25022B0024 0001 (1).pdf PDF
Attachment XII - Project Manual Vol 1.pdf PDF
Attachment VI - DBA WD-2.pdf PDF
Attachment X - American Standard Wall-Hung Lavatory.pdf PDF
Attachment VII - VHA_Directive_1192.pdf PDF
36C25022B0024 (1).pdf PDF
Attachment IX - Eternity Deck Mounted Centerset Faucet.pdf PDF
Attachment XI - American Standard Urinal.pdf PDF
Attachment VIII - American Standard TMV.pdf PDF
Attachment I - Project Manual Vol 2.pdf PDF
Attachment III - Drawings - Combined.pdf PDF
Attachment V - RFI Form-36C25022B0024.doc DOC document
Attachment II - Basis of Design.pdf PDF
36C25022B0024_1.docx DOCX document
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Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Project 610A4-21-105:

Company Name: Address: Telephone: Fax: Email: Contact:

1. Utilizing your OSHA 300 Forms, please complete the following information:

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.

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 six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 238220

3. Who administers your company’s Safety and Health Program?

4. Company’s Insurance Experience Modification Rate (EMR):

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