Contractor EMR Certification Form 2020.pdf
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- Solicitation number
- 36C25020B0074
About this file
This document contains a pre-solicitation announcement and contractor experience modification rate form. The Department of Veterans Affairs will issue a solicitation on August 11, 2020 for upgrade of HVAC systems at various buildings at the Battle Creek VA Medical Center in Michigan. The project number is 515-19-101 and has an estimated value between $2-5 million. The contract type will be firm fixed price with a 545 day period of performance. The work includes furnishing all labor, materials, equipment and documentation to upgrade HVAC systems. The NAICS code is 238220 and it is a 100% set-aside for SDVOSBs. The solicitation will be available for download at sam.gov and bids are due on a date specified in the solicitation. The contractor experience modification rate form requests safety program and insurance information from prospective contractors to determine responsibility.
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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 36C25020B0074 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): ______ http://www.osha.gov/pls/publications/publication.html
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