ATTACHMENT 1 - EMR.pdf
PDF 77 KB Posted
- Solicitation number
- 36C24822R0104
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity from the Department of Veterans Affairs. The form requests company information including number of man hours, OSHA recordable cases, DART rate, serious violations, NAICS code, safety program administrator, and experience modification rate over three years. The federal contract opportunity is for the replacement of the roof and gutter system at Building 10 of the West Palm Beach VA Medical Center.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24822R0104 0001.docx | DOCX document | |
| ATTACHMENT 8 SPEC 014219.pdf | ||
| ATTACHMENT 4 PAST PERFORMANCE REFERENCE QUESTIONNAIRE.pdf | ||
| ATTACHMENT 3 LOS CERTIFICATION SOLICITATION.pdf | ||
| ATTACHMENT 10 AS BUILTS EXISTING ROOF BUILDING 10.pdf | ||
| ATTACHMENT 6 SPEC 01321615.docx | DOCX document | |
| ATTACHMENT 7 SPEC 013526.docx | DOCX document | |
| 36C24822R0104.docx | DOCX document | |
| ATTACHMENT 2 CONTRACTORS INQUIRY.pdf | ||
| ATTACHMENT 9 VAMC SITE MAP .pdf | ||
| ATTACHMENT 5 SPEC 076114.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 .