ATTACHMENT N - EMR.pdf
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- Attached to
- Z2DB--PROJECT 675-23-102, Design-Build (DB) Renovate Building 500 Eye and Audiology Clinic
- Solicitation number
- 36C24823R0110
About this file
This solicitation requests design-build services for the renovation of an eye and audiology clinic at a Department of Veterans Affairs medical center. The project involves all labor, materials, tools and equipment necessary for the design and construction of the renovation. The period of performance is 314 calendar days from notice to proceed. The location of performance is the Orlando VA Medical Center Lake Baldwin Outpatient Clinic in Orlando, Florida. The estimated value is between $2 million to $5 million. The NAICS code is 236220 and the product service code is Z2DB. This is a two-phase design-build solicitation that will utilize a tradeoff source selection process and evaluate proposals to determine best value. Interested firms must be registered in SAM and VetCert as a service-disabled veteran-owned small business to be considered. The selected contractor must comply with environmental laws and policies and incorporate pollution prevention into operations.
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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 2019 2020 2021 2022 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 .