Attachment 4 - EMR (1 Page).docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24822R0132
About this file
This document contains an EMR evaluation form and details of a federal contract opportunity for design and construction services. The EMR form requests safety performance data from the past three years, including total man hours, OSHA recordable incidents, days away from work rates, and violations. Bidders must provide supporting documentation and insurance modification rates.
The federal contract opportunity is with the Department of Veterans Affairs to renovate an MRI room at a VA medical center. It involves removing existing MRI equipment before beginning construction to install new medical equipment. Relevant details include the solicitation and project numbers, opportunity type as a pre-solicitation, requirement for design and construction services including equipment removal, and location as an MRI room renovation at a VA medical facility.
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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 .