ATCH 4 - EMR (1 PAGE).docx
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- Solicitation number
- 36C24823R0097
About this file
This document contains a pre-award contractor evaluation form and details of a federal solicitation for design-build installation site preparation for medical waste equipment. The evaluation form requests information on company safety records including OSHA forms, NAICS code, safety program administration, and experience modification rates over three years. Offerors must submit the completed evaluation form with proposals.
The solicitation is for a two-phase design-build project at the Orlando VA Medical Center to install site preparation for a cart washer. The project value is between $500,000 and $1,000,000. Proposals are due by the cutoff date specified in the solicitation for phase one evaluation. No site visit will be conducted in phase one. The period of performance is 225 days from notice to proceed. The Department of Veterans Affairs Veterans Health Administration VISN 8 is the contracting agency.
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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 .