Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Attached to
- Upgrade Restrooms 506-20-210 Federal contract opportunity
- Solicitation number
- 36C25021B0066
About this file
This document contains a pre-award contractor experience modification rate form and details of a federal contract solicitation for upgrade restroom renovations. The form requests contact and safety program administration information from offerors, as well as OSHA recordable incident rates and experience modification rates over the past three years. It seeks NAICS codes and attachments including recent OSHA forms and proof of insurance rates. The solicitation is for renovations to restrooms and adjacent spaces across three buildings at the Ann Arbor VA Medical Center totaling 2,183 square feet. The scope includes new plumbing, fixtures, finishes and equipment in phases, along with safety barriers and cleaning. The work must comply with manufacturer, code and facility standards while avoiding operational disruptions. Normal hours are defined with provisions for exceptions by approval.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25021B0066 Amendment 0003.pdf | ||
| 36C25021B0066 Amendment 0002.pdf | ||
| 36C25021B0066.pdf | ||
| 36C25021B0066 Amendment 0001.pdf | ||
| SOW Upgrade Restrooms - 506-20-210.pdf | ||
| Wage Determination - Washtenaw County.pdf | ||
| Specifications 506-20-210 Upgrade Restrooms.pdf | ||
| RFI Form Solicitation.doc | DOC document | |
| Drawings Project 506-20-210 Upgrade Restrooms.pdf | ||
| 36C25021B0066.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 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): ______
File details come from the government source that posted it. Updated .