Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25021B0041
About this file
This notice provides information for a planned renovation project at the John D. Dingell VA Medical Center in Detroit, Michigan. The project scope involves renovating seven restrooms on the first floor to be completed over an 80 calendar day performance period. The solicitation will be issued on May 5, 2021 as a 100% set-aside for verified Service-Disabled Veteran Owned Small Businesses. 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 government estimates the project cost to be between $500,000 and $1,000,000 to be awarded as a firm fixed price contract within 120 days of bid opening. Interested contractors must be registered in the System for Award Management and Vendor Information Pages databases. Questions should be directed to the specified contracting officer by email only.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25021B0041.docx | DOCX document | |
| Wage Determination.pdf | ||
| 553-21-203 Renovate First Floor Restrooms SOW.pdf | ||
| Drawings.pdf | ||
| Specifications.pdf | ||
| RFI Form Solicitation.doc | DOC 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 36C25021B0041 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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