Attachment 6 - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24821R0129
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity to renovate clinical research laboratories. The pre-award form requests company information, OSHA record data from the past three years including man hours, injury cases, and violation details. It also requires the company's NAICS code and safety program administrator. Contractors must have an experience modification rate of 1.0 or below over the past three years. The federal contract opportunity is a sources sought notice from the Department of Veterans Affairs to identify qualified Service-Disabled Veteran Owned Small Businesses for a bid build renovation project. Interested firms are requested to submit past performance demonstrating their ability to perform demolition, site preparation, and construction work for clinical research laboratories. Responses are due by email by May 28, 2021 for information and planning purposes.
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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 .