EMR Certification Form - 506-20-103.pdf
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- Solicitation number
- 36C25023B0057
About this file
This document provides information on an upcoming federal contract opportunity for construction services. The Department of Veterans Affairs intends to issue an Invitation for Bid on May 27, 2023 for upgrades to the primary care building at the LTC Charles S. Kettles Veterans Administration Medical Center in Ann Arbor, Michigan. The project involves internal demolition and full reconstruction of the existing primary care area, with an estimated cost between $5-10 million. The contract will have a period of performance of 550 days from bid opening. This acquisition is set aside solely for qualified Service-Disabled Veteran Owned Small Businesses. The NAICS code is 236220 and the small business size standard is $45 million. Offerors must register in the System for Award Management and Vendor Information Pages databases. The first attachment requests safety and health records from prospective contractors to evaluate responsibility.
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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 36C25023B0057 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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