Contractor EMR Certification Form 2021 - 506-CSI-114.pdf
PDF 141 KB Posted
- Attached to
- Z1DA--Site Prep Cardiology EP Labs 506-CSI-114
- Solicitation number
- 36C25021B0046
About this file
This document provides details for a federal construction contract opportunity with the Department of Veterans Affairs for site preparation work at the Ann Arbor VA Medical Center in Michigan. The solicitation will be issued on May 25, 2021 on beta.sam.gov as a 100% set-aside for service-disabled veteran-owned small businesses. The contractor will reconfigure existing space and complete associated site work to support the acquisition and installation of new cardiology electrophysiology laboratory medical equipment. Specific requirements include structural modifications, HVAC, electrical, medical gas, and fire protection system work. The contractor must coordinate with the medical equipment provider and be responsible for successful equipment installation and operation. The period of performance is 120 days. The contract type will be firm fixed price, and the award amount is estimated between $500,000 to $1,000,000.
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Other files
| File | Type | Posted |
|---|---|---|
| EP Labs Barrier Blueprint - ICRA drawing.pdf | ||
| RFI17_36C25021B0046 - RB Construction RFI 010_Response_210629.pdf | ||
| 36C25021B0046 0005.docx | DOCX document | |
| 36C25021B0046 0004.docx | DOCX document | |
| S04 - Pre-Bid Site Visit Meeting Agenda 506-CSI-114.pdf | ||
| S05 - RFIs - Answers to Vendor Questions.pdf | ||
| 36C25021B0046 0003.docx | DOCX document | |
| S04 - Pre-Bid Site Visit Attendance Log 506-CSI-114.pdf | ||
| 36C25021B0046 0002.docx | DOCX document | |
| 36C25021B0046 0001.docx | DOCX document | |
| Specifications 506-CSI-114.pdf | ||
| Wage Determination MI20210100 2-26-2021.pdf | ||
| REQUEST FOR INFORMATION (RFI) Form 506-CSI-114.pdf | ||
| 36C25021B0046_1.docx | DOCX document | |
| Drawings 506-CSI-114.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 36C25021B0046 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 .