Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Site Prep for PET/MRI 553-CSI-006
- Solicitation number
- 36C25020B0041
About this file
This document contains a pre-solicitation announcement and contractor experience modification rate form regarding a federal construction contract opportunity. The Department of Veterans Affairs will be soliciting fixed price bids to renovate approximately 2,200 square feet at the John D. Dingle VA Medical Center in Detroit, Michigan to support new PET/MRI equipment. Renovations will include upgrading existing rooms, adding new patient support spaces like uptake/dosing rooms and a hot lab, and relocating other spaces. The contractor will be required to complete the work within 120 days and hold all necessary licensing and insurance. The NAICS code for this project is 238990 and the size standard of $16.5 million applies. Interested contractors should monitor the beta.SAM.gov website where the solicitation will be posted on or around May 30th with bids due as specified. The contractor experience modification rate form requests safety history and worker's compensation insurance information to evaluate contractor responsibility.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25020B0041 0009.docx | DOCX document | |
| 36C25020B0041 0008.docx | DOCX document | |
| 36C25020B0041 0007.docx | DOCX document | |
| 19.1010 - 2020.07.16 - Addendum 1 Sheet AS302.pdf | ||
| 553-CSI-006 RFI answers 1.docx | DOCX document | |
| 36C25020B0041 0006.docx | DOCX document | |
| 36C25020B0041 0005.docx | DOCX document | |
| 36C25020B0041 0004.docx | DOCX document | |
| 553-CSI-006 RFI answers.docx | DOCX document | |
| 553-CSI-006 Attendance Log .pdf | ||
| 36C25020B0041 0003.docx | DOCX document | |
| 553-CSI-006 - Addendum 1 Sheet AS302.pdf | ||
| 553-CSI-006 - Drawing Set.pdf | ||
| 36C25020B0041 0001.docx | DOCX document | |
| 36C25020B0041.docx | DOCX document | |
| Project 553-CSI-006 - Spec Vol 1 Div00 14.pdf | ||
| Wage Determination M120200101.txt | TXT text file | |
| Project 553-CSI-006 - Bid Documents Drawing Set.pdf | ||
| Project 553-CSI-006 - Spec Vol 2 Div21 28.pdf |
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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 36C25020B0041to 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 |
| 201 |
| 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 .