Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Upgrade Elevators 506-19-102 Federal contract opportunity
- Solicitation number
- 36C25020B0044
About this file
This document contains a pre-solicitation announcement and related contractor experience form for an upcoming construction project solicitation by the Department of Veterans Affairs. The solicitation will require a contractor to repair and renovate parking structures at the VA Medical Center in Ann Arbor, Michigan, including repairing concrete, installing fall protection systems, replacing lighting and signage, repairing storm piping and roof leaks, and adding ventilation to stairwells. The project value is estimated between $2-5 million. The solicitation will be issued on June 10, 2020 via beta.SAM.gov under NAICS code 238990 with a size standard of $16.5 million. The contractor will be provided 380 days to complete the work and a firm fixed price contract will be awarded within 120 days of bid receipt. The pre-solicitation form requests relevant safety history from prospective contractors including OSHA recordkeeping data, certifications, and insurance experience modification rates.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25020B0044 0006.docx | DOCX document | |
| The project is not tax exempt.docx | DOCX document | |
| 36C25020B0044 0005.docx | DOCX document | |
| Addendum - 01 EP401 r1.pdf | ||
| 36C25020B0044 0004.docx | DOCX document | |
| RFI Combine answers.docx | DOCX document | |
| Addendum - 01 GI104 r1.pdf | ||
| Addendum - 01 Elevator Pit Ladder detail.pdf | ||
| Addendum - 01 EP001 r1.pdf | ||
| 055000 Metal Fabrications r01.pdf | ||
| 36C25020B0044 0003.docx | DOCX document | |
| 506-19-102 Elevators - Pre-Bid attendance.pdf | ||
| 36C25020B0044 0001.docx | DOCX document | |
| 36C25020B0044 0002.docx | DOCX document | |
| MI20200100 01-24-2020.pdf | ||
| S02 - RFI Form 506-19-102.docx | DOCX document | |
| 506-19-102 - Bid Docs Specs .pdf | ||
| 506-19-102 Bid Documents Drawings .pdf | ||
| 36C25020B0044_2.docx | DOCX document |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25020B0044 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): ______
File details come from the government source that posted it. Updated .