Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25020B0058
About this file
This document contains a pre-award contractor experience modification rate form and details of a related federal contract opportunity for renovation work. The form requests safety and insurance experience information from prospective contractors, including OSHA recordable incident rates, violations, and experience modification rates over the past three years. The related solicitation is for furnishing all labor, materials, and equipment to renovate an outpatient pharmacy and urgent care center for the Battle Creek Healthcare System in Michigan. Sealed bids are due on September 10, 2020 and the project is set aside 100% for Service Disabled Veteran Owned Small Businesses. The required NAICS code is 236220 and the small business size standard is $39.5 million.
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Other files
| File | Type | Posted |
|---|---|---|
| Covid Instructions.docx | DOCX document | |
| 36C25020B0058 0002.docx | DOCX document | |
| 515-18-109 Pre-Bid Attendance Sheet.pdf | ||
| RFi Answers.docx | DOCX document | |
| 515-18-109 Bid Drawings - Signed_Part1 - reissue.pdf | ||
| 36C25020B0058 0001.docx | DOCX document | |
| 515-18-109 Bid Specifications_Part3.pdf | ||
| WD MI20200079 7-24-20.pdf | ||
| 515-18-109 Bid Drawings - Signed_Part1.pdf | ||
| 515-18-109 Bid Drawings - Signed_Part2.pdf | ||
| 515-18-109 Bid Drawings - Signed_Part5.pdf | ||
| 515-18-109 Bid Drawings - Signed_Part3.pdf | ||
| S02 - RFI Form 515-18-109.docx | DOCX document | |
| 515-18-109 Bid Specifications_Part1.pdf | ||
| 515-18-109 Bid Specifications_Part2.pdf | ||
| 36C25020B0058.docx | DOCX document | |
| 515-18-109 Bid Drawings - Signed_Part6.pdf | ||
| 515-18-109 Bid Drawings - Signed_Part4.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 36C25020B0058 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 .