Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25021B0063
About this file
This notice provides information for an upcoming solicitation for improvements to signage and wayfinding at the Battle Creek VA Medical Center in Battle Creek, Michigan. The Department of Veterans Affairs intends to issue an invitation for bid on or around July 28, 2021 for upgrades to existing restrooms and adjacent spaces across three buildings totaling 2,183 square feet. The work will be completed in phases during normal business hours excluding federal holidays. The North American Industry Classification Code is 236220 for Commercial and Institutional Building Construction, with a small business size standard of $39.5 million. The estimated cost is between $500,000 and $1,000,000. The government intends to award a firm fixed price contract within 120 days of bid opening. This acquisition is a 100% set-aside for qualified Service-Disabled Veteran Owned Small Businesses registered in the Vendor Information Pages database. Offerors should monitor the Contract Opportunities website for any updates to this announcement or pending solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| Improve Signage and Wayfinding Drawings.pdf | ||
| RFI Form Solicitation.doc | DOC document | |
| Wage Determination Calhoon County MI.pdf | ||
| Improve Signage and Wayfinding Statement of Work (SOW).pdf | ||
| Specification Improve Signage and Wayfinding.pdf | ||
| 36C25021B0063.docx | DOCX document |
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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 36C25021B063 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: 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): ______
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