EMR Certification Form - 506-21-105.pdf
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- Solicitation number
- 36C25024B0028
About this file
This document provides information on a planned solicitation for interior signage replacement services at a Veterans Affairs medical center. The Department of Veterans Affairs intends to issue an invitation for bid on or about January 8, 2024 for project 506-21-105 to replace or enhance all interior signage at the LTC Charles S. Kettles VAMC located in Ann Arbor, Michigan. The project magnitude is estimated between $2,000,000 and $5,000,000 to be awarded as a firm fixed price contract within 120 days of bid opening. The North American Industry Classification Code for this procurement is 238990 for all other specialty trade contractors, with a small business size standard of $19 million. This acquisition is set aside for qualified Service-Disabled Veteran Owned Small Businesses. Offerors must be verified in the Veteran Small Business Certification database and registered in the System for Award Management at the time of proposal submission to be eligible for consideration.
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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 36C25024B0028 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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