515-18-201 - Contractor EMR Certification Form 2021.docx
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- Attached to
- Z1DA--Upgrade and Expand Security Camera's 515-18-201 Federal contract opportunity
- Solicitation number
- 36C25021B0033
About this file
This document contains a pre-solicitation announcement and related contractor experience modification rate form for an upcoming construction project to upgrade and expand security cameras at a Department of Veterans Affairs medical center. The announcement seeks bids for a firm fixed price contract to remove existing security cameras and wiring, install new IP cameras using CAT6A and fiber optic cable along with supporting network infrastructure including patch panels, switches and NVRs. New security camera monitoring software will also be provided. Interested contractors must complete the experience modification rate form providing OSHA recordable incident data and insurance rates for the past three years. Bids are due on or before the date specified in the forthcoming solicitation to be issued on May 30, 2020. The project value is between $1,000,000 and $5,000,000 and work must be completed within 180 days of award.
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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 36C250 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 |
| 2017 |
| 2018 |
| 2019 |
| 2020 |
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)2019 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 .