Contractor EMR Certification Form 2020.docx
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- Attached to
- Z1DA-- Repair Parking Structure - 506-19-103 Federal contract opportunity
- Solicitation number
- 36C25020B0045
About this file
This document contains a pre-solicitation announcement and related federal contract opportunity notice. The Department of Veterans Affairs will issue an Invitation for Bid on June 10, 2020 for project number 506-19-103 to repair parking structures at the VA Medical Center in Ann Arbor, Michigan. The project scope includes concrete repairs, fall protection installations, lighting replacements, tuckpointing, expansion joint and storm piping replacements, painting, signage replacements, and stairwell renovations. The contractor will have 380 days to complete the work. The North American Industry Classification code for this procurement is 2389900 and the size standard is $16.5 million. The contract value is estimated between $1-5 million. The government intends to award a firm fixed price contract within 120 days of bid receipt. All questions must be submitted in writing to the email address provided by the specified date.
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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 .