Attach 04 EMR (1 Page).docx
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- Attached to
- Y1NZ--FY22: NRM Tier-1 (PROJ 675-22-112) DB Upgrade Lake Nona Building Automation System Infrastructure
- Solicitation number
- 36C24822R0004
About this file
This document contains a pre-award evaluation form and details of a federal contract opportunity. The pre-award form requests company information including number of man hours, OSHA case data, violation details, NAICS code, and safety program administrator from bidders. The federal contract opportunity is a solicitation to replace the existing building automation system infrastructure at the Lake Nona VA Medical Center campus in Orlando, Florida. It will replace LonWorks controllers and devices with BACnet protocol controllers and wiring will be upgraded from 2-wire to 3-wire. The replacement is through a design-build project with a magnitude over $10 million. The solicitation will be issued on November 1, 2021 via beta.SAM.gov and is set aside for 100% service-disabled veteran-owned small businesses. The response deadline is October 22, 2021.
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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 |
| 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. (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 .