ATTACHMENT H - EMR.pdf
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- Solicitation number
- 36C24822R0093
About this file
This document contains a federal solicitation for design-build services for police upgrades at two Department of Veterans Affairs medical facilities. The solicitation is a 100% set-aside for verified Service-Disabled Veteran-Owned Small Businesses. The scope of work includes all design and construction services for police upgrades at the VA medical centers in Viera and Orlando, Florida. The period of performance is 292 calendar days from notice to proceed. The estimated value of the contract is between $250,000 and $500,000. Proposals are due by responding to solicitation number 36C24822R0093 and will be evaluated using a two-phase design-build source selection process and FAR Part 15. Interested offerors must be registered in the System for Award Management and VetBiz databases by the time of proposal submission. The primary point of contact for the solicitation is the contracting officer.
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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 2018 2019 2020 2021 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): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .