EMR Certification Form - 506-20-102.pdf
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- Solicitation number
- 36C25023B0027
About this file
This document provides information on a planned solicitation for interior renovation services. The Department of Veterans Affairs intends to issue an Invitation for Bids on or around March 20, 2023 for Project 506-20-102 to upgrade approximately 14,000 square feet of existing basement, sub-basement, electrical shop, and recreation therapy office space at the LTC Charles S. Kettles Veterans Administration Medical Center in Ann Arbor, Michigan. The scope of work includes mechanical, electrical, and plumbing system upgrades, as well as asbestos abatement. The acquisition is a total small business set-aside for qualified Service-Disabled Veteran Owned Small Businesses. The North American Industry Classification code is 236220 and the estimated value is between $1 million and $5 million. A firm fixed-price contract is expected to be awarded within 120 days of bid opening. All solicitation documents will be available on SAM.gov starting on or around the planned issuance 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 36C25023B0027 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 2023
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)2023 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
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