Contractor EMR Certification Form 2020 - 515-20-103.pdf
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- Solicitation number
- 36C25021B0005
About this file
This document contains a pre-solicitation announcement for a construction project at the Department of Veterans Affairs Medical Center in Battle Creek, Michigan. The project involves renovating a portion of the second floor of Building 7 to house Mental Health programs and various Mental Health service staff. The contractor will receive 280 days to complete the work. The project value is estimated between $1 million and $2 million. The solicitation will be issued on November 30, 2020 via the Contract Opportunities website as a 100% set-aside for Service-Disabled Veteran Owned Small Businesses. Interested parties should register on Contract Opportunities and monitor the site for solicitation details including the response due date. The selected contractor will be awarded a firm fixed-price contract within 180 days of bid receipt.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25021B0005 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 2016 2017 2018 2019
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: 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.
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): ______ http://www.osha.gov/pls/publications/publication.html
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