553-21-706- Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA-- 553-21-706-DDPO EHRM Site Prep Federal contract opportunity
- Solicitation number
- 36C25021B0062
About this file
This document contains a pre-solicitation announcement and related contractor experience modification rate form for an upcoming Department of Veterans Affairs construction project. The VA will issue an invitation for bid on or around July 28, 2021 for construction services at the John D. Dingell VA Medical Center in Detroit, Michigan. The project involves installing 251 hospital-grade duplex receptacles, 332 terminated and tested CAT-6A cables, conduit, raceways, and fire stopping from data/electrical closets to equipment locations throughout the medical center. Bids are due within 60 days of issuance, and the VA intends to award a firm fixed-price contract valued between $1-5 million also within 60 days of bid receipt. The pre-award form requests contractors provide OSHA recordable incident rates, copies of OSHA forms and insurance modification rates, and safety program details. The NAICS code for this project is 238210 and the size standard is $16.5 million.
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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 36C25021B0062 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 .