Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Attached to
- J041--506-20-209 Replace Air Handler Bldg 31 - 1 and 2 Federal contract opportunity
- Solicitation number
- 36C25020B0055
About this file
This document contains a pre-solicitation announcement and a contractor experience modification rate form. The announcement is for project number 506-20-209 to replace air handlers at building 31 of the Ann Arbor VA Medical Center in Ann Arbor, Michigan. The project scope involves removing and replacing cooling coils, heating coils, and other internal components in air handler units 1 and 2. Additional work includes repairing interior and exterior casing rust. The project is to be completed within 120 days of award. The NAICS code is 238220 and award is estimated between $500,000 to $1 million as a firm fixed price contract. The pre-solicitation form requests contractor safety experience information over the past three years including OSHA recordable incidents and experience modification rates. Responses are due by the date specified in the forthcoming solicitation to be posted on beta.SAM.gov on or around June 30, 2020.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Sign In Sheet 506-20-209.pdf | ||
| 36C25020B0055 0004.docx | DOCX document | |
| Covid Instructions.docx | DOCX document | |
| 36 A103.pdf | ||
| 36C25020B0055 0002.docx | DOCX document | |
| 01 G001.pdf | ||
| 03 G002.pdf | ||
| 48 - MH100 - BASEMENT HVAC PLAN.pdf | ||
| 47 - M001 - GENERAL MECHANICAL INFORMATION.pdf | ||
| 48 - MH103 - MECHANICAL HVAC PENTHOUSE PLAN.pdf | ||
| 36 A320.pdf | ||
| 36C25020B0055 0003.docx | DOCX document | |
| RFI Form 506-20-209.docx | DOCX document | |
| 36C25020B0055_1.docx | DOCX document | |
| 506-20-209 AHU - Specifications.pdf | ||
| 506-20-209 - VA AA AHU Replacement - Bid Drawings.pdf | ||
| WD- ML20200100 07-24-2020.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 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 .