S02 - Contractor EMR Certification Form -506-20-101.pdf
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- Attached to
- Z1DA--Increase Mental Health Beds 506-20-101
- Solicitation number
- 36C25022B0051
About this file
This document provides details of a pre-solicitation notice for a planned invitation for bid to increase mental health beds at a Veterans Administration medical center. The project involves renovating an acute inpatient mental health unit and adjacent outpatient mental health unit, including demolition, installation, and commissioning to provide a complete and usable mental health unit. The work is to be performed during normal business hours excluding federal holidays. The NAICS code is 236220 for commercial and institutional building construction with a small business size standard of $39.5 million. The estimated cost is between $5-10 million. The government intends to award a firm fixed price contract within 120 days of bid opening. This acquisition is reserved as a 100% set-aside for verified service-disabled veteran-owned small businesses. Interested offerors should monitor the Contract Opportunities website for the full solicitation planned for release on or about May 30, 2022, which will include further details on submission requirements, site visits, and the bid due date.
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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 36C25022B0051 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 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: a)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. b)Letter from insurance carrier stating current EMR rate.
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
File details come from the government source that posted it. Updated .