Attachment 08 - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24822R0157
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for electrical panelboard deficiency corrections. The pre-award form requests company information including North American Industry Classification System code, OSHA recordable incident rates for the past three years, safety program administration, and experience modification rates. Bidders must also attach copies of OSHA Forms 300 and 300A. The related federal contract opportunity is a solicitation to correct electrical panelboard deficiencies at Building 1 located at the Gainesville VA Medical Center. A pre-bid site visit is scheduled for August 10th, 2022. Proposals are due by August 31st, 2022 at 3:30 PM. This requirement is set aside for Service-Disabled Veteran-Owned Small Businesses. The contracting agency is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment 07 - Past Performance Questions.docx | DOCX document | |
| Attachment 04 - Wage Determination.pdf | ||
| S02 - SOLICITATION - Correct Electric PanelBoard - 36C24822R0157.pdf | ||
| Attachment 11 - VHA Supplemental Contract Requirements for Combatting COVID-19.docx | DOCX document | |
| Attachment 09 - Experience Information Sheet.docx | DOCX document | |
| Attachment 06 -Price Metric.xls | XLS spreadsheet | |
| Attachment 05 - LOS Certification.doc | DOC document | |
| Attachment 02 - Drawing.pdf | ||
| Attachment 01 - Statement of Work.docx | DOCX document | |
| Attachment 10 - Specialized Experience Form.pdf | ||
| Attachment 03 - Specifications.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 |
| 2019 |
| 2020 |
| 2021 |
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 .