ATTACHMENT D - EMR.pdf
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- Solicitation number
- 36C24821R0095
About this file
This document contains a federal contract opportunity solicitation for design-build services to replace cooling towers at a Department of Veterans Affairs medical center. The solicitation seeks proposals to provide all design, construction, labor, materials and equipment to install two new cooling towers and associated piping and infrastructure at the Orlando VA Healthcare System Lake Baldwin campus in Orlando, Florida. The estimated project completion period is 360 calendar days from notice to proceed. The requirement has an estimated value between $1-5 million and is set aside exclusively for Service-Disabled Veteran-Owned Small Businesses. The North American Industry Classification System code for this project is 236220 for commercial and institutional building construction. The solicitation is expected to be issued on or around July 21, 2021 and all interested firms must be registered in the System for Award Management and VetBiz databases. Proposals are due at the time of solicitation release on the Beta SAM website.
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Text version
EMR FORM
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 2017 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): _____________
ATTACHMENT D {1 PAGE}
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .