Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Repair FCA Deficiencies & Upgrade Elevators Bldg 77 Repair Deficiencies & Upgrade Elevators Bldg 162
- Solicitation number
- 36C24922B0006
About this file
This solicitation document outlines requirements for two federal construction projects to repair deficiencies and upgrade elevators in buildings 77 and 162 at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. The solicitation is a 100% set-aside for service-disabled veteran-owned small businesses. The contractor shall furnish all labor, materials, equipment, supervision and other items to complete the projects, including demolition and removal of existing elevator equipment and commissioning of new elevator operations. The contractor must also complete VA privacy training and enroll in E-Verify within 30 days of award. Bids are due by December 29, 2021 and the contract is estimated at $150,000 or more, requiring annual VETS-4212 reporting.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24922B0006 0003.docx | DOCX document | |
| 36C24922B0006 0002.docx | DOCX document | |
| Bldg. 162 Elevator drawing.pdf | ||
| Bldg.77 Elevator Upgrade Layout.pdf | ||
| Bldg. 162 Elevator Equipment locations Part 2.pdf | ||
| Bldg. 162 Elevator equipment locations Part 1.pdf | ||
| 157-204-H23.pdf | ||
| Bldg. 162 Elevators.pdf | ||
| Bldg. 77 Elevators.pdf | ||
| 36C24922B0006 0001.docx | DOCX document | |
| 36C24922B0006_1.docx | DOCX document | |
| Specs 621-22-123 Repair Deficiencies and Upgrade Elevators Bldg 126 - .pdf | ||
| SOW 621-22-123 Repair FCA Deficiencies and Upgrade Elevators.docx | DOCX document | |
| SOW 621-19-126 - Repair FCA Deficiencies and Upgrade Elevators Bldg 77 - .docx | DOCX document | |
| S02 - RFI Form.docx | DOCX document | |
| Specs 621-19-126 Repair FCA Deficiencies and Upgrade Elevators Bldg 77 .pdf | ||
| WD TN20210111 01-01-2021 .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 36C24921B0001 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 .