Attachment 4 - Contractor EMR Certification Form - 515-24-500.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Battle Creek JOC IDIQ 515-24-500
- Solicitation number
- 36C25025R0070
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Certification Form for Solicitation 36C25025R0070, a Job Order Contract (JOC) IDIQ for the VA Medical Center in Battle Creek, Michigan. The form requires contractors to provide detailed safety and occupational health information, including three years of data on man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Contractors must submit OSHA 300 and 300a forms, an insurance carrier letter stating the current EMR rate, their six-digit NAICS code, and identify the person responsible for their company's Safety and Health Program. The document is designed to assess a contractor's safety performance and organizational responsibility as part of the pre-award evaluation process for this Veterans Health Administration contract.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025R0070 0004.docx | DOCX document | |
| 36C25025R0070 0003.docx | DOCX document | |
| 36C25025R0070 0002.docx | DOCX document | |
| Attachment 10 - Wage Determination - MI20240079 - 4-4-25 - Calhoun MI - 515-24-500.pdf | ||
| 36C25025R0070 0001.docx | DOCX document | |
| Attachment 5 - Safety Reqmts - Spec 01 35 26 - May 2024 - 515-24-500.pdf | ||
| Attachment 3 - RFI Form - 515-24-500.doc | DOC document | |
| Attachment 8 - General Contractor Information - 515-24-500.docx | DOCX document | |
| Attachment 6 - Surety Form - 515-24-500.doc | DOC document | |
| Attachment 7 - Financial Disclosure - 515-24-500.doc | DOC document | |
| 36C25025R0070.docx | DOCX document | |
| Attachment 10 - Wage Determination - MI20240079 - 2-21-25 - Calhoun MI - 515-24-500.pdf | ||
| Attachment 1 - OFFEROR PRICE EVALUATION WORKSHEET JOC IDIQ - 515-24-500.xlsx | XLSX spreadsheet | |
| Attachment 9 - Past Performance Questionnaire - 515-24-500.doc | DOC document | |
| Attachment 2 - ATTACHMENT VAAR 852.219-75 LIMITATIONS OF SUBCONTRACTING CERT - 515-24-500.docx | DOCX document |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to the Solicitation to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2022 |
| 2023 |
| 2024 |
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.
2. Please attach copies of the following documents: a) OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b) Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .