S02 Contractor EMR Certification Form - 553-23-100.pdf
PDF 107 KB Posted
- Attached to
- Z1DA--Thermo Storage Tank Repairs 553-23-100
- Solicitation number
- 36C25024B0064
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Form related to Solicitation 36C25024B0064, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10, for Thermo Storage Tank Repairs 553-23-100.
The form requests the contractor to provide information on their OSHA 300 incident rates, number of OSHA violations, and current EMR rate to assist in determining responsibility in accordance with FAR 9.104-1(e). Specifically, the contractor is asked to provide the number of man-hours, days away/restricted/transferred cases, DART rate, and any OSHA violations for the past 3 calendar years. The contractor must also attach their 2023 OSHA 300 and 300A forms, and a letter from their insurance carrier stating their current EMR rate. Additionally, the contractor must provide their 6-digit NAICS code and the name/title of the person who administers their safety and health program.
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Other files
| File | Type | Posted |
|---|---|---|
| Site Visit Sign-in Sheet - 553-23-100.pdf | ||
| 36C25024B0064 0001.docx | DOCX document | |
| RFI 001- 553-23-100 AE Response.pdf | ||
| Pre-Bid Site Visit Agenda - 553-23-100.pdf | ||
| S02 Specifications - 553-23-101.pdf | ||
| S02 Wage Determination - MI20240101 05 31 2024 - 553-23-100.pdf | ||
| S02 RFI Form - 553-23-100.pdf | ||
| S02 Drawings - 553-23-100.pdf | ||
| 36C25024B0064_1.docx | DOCX document |
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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 36C25024B0064 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
File details come from the government source that posted it. Updated .