Contractor EMR Certification Form 2021 - 506-CSI-113.pdf
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- Attached to
- Z1DA--CSI Site Prep Angio 0R-6 506-CSI-113
- Solicitation number
- 36C25021B0022
About this file
This document contains a pre-solicitation notice and related Contractor Experience Modification Rate (EMR) Form for a construction project at the Ann Arbor VA Medical Center. The Department of Veterans Affairs will issue a solicitation on or around March 9, 2021 via beta.SAM.gov seeking a contractor to complete site preparation work in Operating Room #6 for the installation of new medical equipment. The project involves reconfiguring the space for floors, walls, ceilings and utilities to support the equipment. Interested offerors should register on beta.SAM.gov as the solicitation and any amendments will only be available electronically. The NAICS code is 236220 and size standard is $39.5 million. The government intends to award a firm fixed price contract within 180 days of bid receipt and the contractor will have 180 days to complete the work. The pre-award EMR Form requests company safety data from the past three years such as OSHA recordable incidents, violations, and current EMR 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 36C25021B0022 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 2017 2018 2019 2020
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
File details come from the government source that posted it. Updated .