Attachment D_Contractor EMR Certification Form 2023.docx
DOCX document 16 KB Posted
- Attached to
- Z1DA--652-24-108 Replace Roofs and Flashing Federal contract opportunity
- Solicitation number
- 36C24624R0064
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Form, which is being requested as part of the solicitation process for the federal contract opportunity to Replace Roofs and Flashing for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 6.
The form requires the contractor to provide information about their safety record, including the number of man-hours, cases involving days away from work, the Days Away, Restricted, or Transferred (DART) rate, and any OSHA violations over the past three years. The contractor must also attach their OSHA 300 and 300A forms, a letter from their insurance carrier stating their current EMR rate, and identify the NAICS code and the person who administers their safety and health program. The EMR rate is being requested to assist in the initial determination of the contractor's responsibility in accordance with FAR 9.104-1(e).
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24624R0064 0004.docx | DOCX document | |
| S02_Solicitation_36C24624R0064 0004.docx | DOCX document | |
| 36C24624R0064 0003.docx | DOCX document | |
| Specification New Guardrail System_SECTION 05 52 13.pdf | ||
| Questions and Answers_2.pdf | ||
| 36C24624R0064 0002.docx | DOCX document | |
| Questions and Answers_1.pdf | ||
| Site Visit Attendance Log 06-07-2024.pdf | ||
| 36C24624R0064 0001.docx | DOCX document | |
| 652-24-108 Combined Specifications_10Jun2024.pdf | ||
| Attachment E_652-24-108 Replace Roofs and Flashing CD_8Jun2023.pdf | ||
| Attachment C_Past Performance Questionnaire Form.docx | DOCX document | |
| Attachment B_Relevant Corporate Experience Form.docx | DOCX document | |
| Attachment A_Wage Determination General Decision Number VA20240007 03292024.pdf | ||
| Attachment F_Itemized Schedule of Values Cost Breakdown.xlsx | XLSX spreadsheet | |
| 36C24624R0064.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 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 |
| 2021 |
| 2022 |
| 2023 |
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) 2019 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 .