Attachment 6 - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24821R0131
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity. The pre-award form requests company information including number of man hours, OSHA case data from 2018-2020, NAICS code, safety program administrator, and experience modification rates for the past three years. The federal contract opportunity is a set-aside for Service-Disabled Veteran-Owned Small Businesses issued by the Department of Veterans Affairs Network Contracting Office to install new parking garage infrastructure at the Lake Nona VA Medical Center in Orlando, Florida. The magnitude of construction is estimated between $1,000,000 to $5,000,000. Interested firms must be registered in SAM.gov, with responses due by July 20, 2021. The solicitation is scheduled for issue on or around July 20, 2021 and will be posted on beta.SAM.gov.
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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 |
| 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 .