Attachment 02 - EMR.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C24821R0103
About this file
This solicitation requests proposals for a two-phase design-build project to replace flanged valves hospital-wide at a Veterans Affairs medical center. The project is set aside exclusively for service-disabled veteran-owned small businesses. Offerors must complete an Experience Modification Rate form and provide OSHA 300 forms from the past three years, as well as their NAICS code and safety program administrator information. The solicitation includes attachments specifying the statement of work, experience information sheet, cost breakdown form, general requirements, network analysis schedules, reference standards, and applicable wage determination. Proposals are due by the date listed in the solicitation.
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Text version
36C24821R0103 – Attch. 01
EMR FORM
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 |
| 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. (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 .