Contractor EMR Certification Form 2020.docx
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- Solicitation number
- 36C24921B0001
About this file
This document contains a pre-award contractor experience modification rate form and information on a related federal contract opportunity for renovating a Whole Health Clinic. The form requests contact information and safety data from the past three years, including man hours, OSHA recordable incidents, days away from work rates, and violations. It also requests NAICS code, safety program administrator name and title, and insurance EMR for the acquisition. The related federal contract opportunity is to furnish all labor, materials and equipment to prepare the site and complete renovations for the Whole Health Clinic at the Alvin C. York VA Medical Center in Murfreesboro, Tennessee, with a bid opening of November 9, 2020 at 10:00 AM Central Time. The contracting agency is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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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 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 .