ATTACHMENT E - EMR FORM.pdf
PDF 143 KB Posted
- Solicitation number
- 36C24822R0135
About this file
This solicitation is for design-build services to replace a computed tomography scanner at a Veterans Affairs medical center. The Department of Veterans Affairs is seeking proposals for the design and construction of the project, including labor, materials, tools, equipment, and all other resources necessary. The period of performance is 310 calendar days from the notice to proceed. The project location is the Bruce W. Carter VA Medical Center in Miami, Florida, with a magnitude between $250,000 and $500,000. The associated North American Industry Classification System code is 236220 for commercial and institutional building construction. This solicitation will utilize a two-phase design-build selection process and a trade-off source selection method providing best value to the government. Proposals are due by responding to solicitation number 36C24822R0135 and its attachments.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24822R0135 0001.docx | DOCX document | |
| Amendment 36C24822R0135 0001.pdf | ||
| SOLICITATION - 36C24822R0135.pdf | ||
| ATTACHMENT A - 01 00 00 GENERAL REQUIREMENTS.pdf | ||
| ATTACHMENT F - EXPERIENCE INFORMATION SHEET.pdf | ||
| 36C24822R0135_1.docx | DOCX document | |
| ATTACHMENT D - LIMITATION ON SUBCONTRACTING CERTIFICATION.docx | DOCX document | |
| ATTACHMENT B - FLOOR PLANS - DRAWINGS.pdf | ||
| ATTACHMENT C - DAVIS BACON ACT WD FL20210215.pdf | ||
| ATTACHMENT G - PAST PERFORMANCE QUESTIONNAIRE.docx | DOCX document |
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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 201 201 201 20 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): _____________
E
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