553-21-205 Contractor EMR Certification Form 2020.docx
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- Attached to
- Z1DA--553-21-205 Replace Steam Station
- Solicitation number
- 36C25020B0073
About this file
This document contains a pre-solicitation announcement and contractor experience modification rate form regarding a construction project for the Department of Veterans Affairs Medical Center in Detroit, Michigan. The VA is seeking a qualified contractor to furnish all labor, materials, tools, equipment, permits and supervision necessary to demolish existing structures and install a new anti-climb fencing system with all required features in the red and blue parking structures, as specified in the drawings and specifications. Interested offerors should complete the contractor EMR certification form providing OSHA recordable incident rates, violation information if applicable, and insurance EMR for the past three years. The NAICS code for this project is 238990 and the project value is estimated between $1 million to $5 million. The solicitation will be issued on May 20, 2020 via beta.SAM.gov and responses are due as specified in the solicitation.
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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 36C25020B0073 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 |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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: 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.
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 .