ATCH 4 - EMR (1 PAGE).docx
DOCX document 14 KB Posted
- Attached to
- Design Build - Renovate Dish Room - Miami, FL
- Solicitation number
- 36C24823R0072_01
About this file
This document includes a pre-award evaluation form and details of a federal contract opportunity for design-build renovation of a dish room at a Veterans Affairs medical center in Miami, Florida. The pre-award form requests company information including number of man hours, OSHA recordable incidents, insurance experience modification rate, and safety program administration. The federal contract opportunity is set aside for service-disabled veteran-owned small businesses and involves renovating the dish room for $500,000 to $1,000,000. Proposals are due in two phases with an initial evaluation followed by more detailed proposals from selected offerors. The work must be completed by a certified SDVOSB contractor and will take place at the smoke-free Miami VAMC medical campus requiring COVID-19 screening and face coverings.
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Other files
| File | Type | Posted |
|---|---|---|
| ATCH 1 - DOL Wage Determination.pdf | ||
| ATCH 3 - Past Performance Questionnaire.pdf | ||
| ATCH 2 - PRICE MATRIX.xlsx | XLSX spreadsheet | |
| ATCH 5 - Specialized Experience Form (3 Pages) - EXAMPLE.pdf | ||
| SOLICITATION 36C24823R0072.pdf |
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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. (Four serious, one repeat, or one willful disqualifies the contractor.)
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
2. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program? __________________________________
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________
File details come from the government source that posted it. Updated .