S02 Contractor EMR Certification Form - 506-21-102.docx
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- Attached to
- Z1DA--Modernize Building 22 506-21-102 Federal contract opportunity
- Solicitation number
- 36C25023B0005
About this file
This document provides details for a pre-solicitation notice for a construction project to modernize Building 22 at the LTC Charles S. Kettles Veterans Administration Medical Center in Ann Arbor, Michigan. The Department of Veterans Affairs intends to issue an invitation for bid on or around November 30th, 2022 for a firm fixed price construction contract with a value between $5 million and $10 million. The project involves furnishing all labor, materials, equipment and supervision to complete the modernization in accordance with provided drawings, specifications and applicable codes. Work is to be performed during normal daytime business hours excluding federal holidays. The North American Industry Classification System code for this procurement is 236220. The acquisition is reserved solely for Service-Disabled Veteran Owned Small Businesses verified in the Vendor Information Pages database. Questions must be submitted in writing and the eventual awardee will be required to register in the System for Award Management and have an active VETS-4212 report if applicable.
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25023B0005 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 |
| 2020 |
| 2021 |
| 2022 |
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) 2020 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): ______
File details come from the government source that posted it. Updated .