Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Attached to
- Y1DB--New 4th MRI Addition Project 652-CSI-204
- Solicitation number
- 36C24621R0021
About this file
This document contains a pre-award Contractor Experience Modification Rate form and details for a federal solicitation to provide construction services. The form requests information on the contractor's OSHA 300 forms, serious violations, and experience modification rate from their insurance carrier for the past three years. It also requires the contractor's NAICS code and identifies the safety program administrator.
The related federal solicitation is for project 652-CSI-204 to provide a new approximately 2,785 square foot single story addition to an existing MRI suite at a Veterans Affairs medical facility. The addition will house two new MRIs and match the exterior and interior finishes of the existing building. The scope also includes relocating an existing MRI trailer and services. The solicitation is issued by the VA Veterans Health Administration VISN 6.
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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 36C246 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: a)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. b)Letter from insurance carrier stating current EMR rate.
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 .