Contractor EMR Certification Form 2020.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--Upgrade 1W Building 506-20-201
- Solicitation number
- 36C25020B0046
About this file
This document contains a pre-award contractor experience modification rate form and details of a federal solicitation for construction renovation services. The form requests safety and health information over the past three years such as man hours, OSHA recordable incidents, days away from work rates, and violations. It also requires copies of OSHA forms, NAICS code, safety program administrator, and insurance EMR. The solicitation is for renovations to an existing audiology and ENT clinic space totaling 4,200 square feet at the Ann Arbor VA Medical Center. The scope of work includes structural, architectural, electrical, mechanical and interior design services to result in complete and usable spaces adhering to building codes, VA standards, LEED, and energy conservation requirements. The period of performance is 180 calendar days from notice to proceed with work commencing in fall 2020. The solicitation was issued by the Department of Veterans Affairs Veterans Health Administration VISN 10.
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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 36C250 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 .