Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25021B00410
About this file
This document contains a pre-award Contractor Experience Modification Rate (EMR) form and details of a related federal contract opportunity to renovate restrooms at the John D. Dingell VA Medical Center in Detroit, Michigan. The EMR form requests safety performance data from the past three years, including man hours, OSHA recordable injuries, days away from work rates, and violations. It asks for copies of OSHA forms, current EMR rate from the contractor's insurance carrier, NAICS code, and safety program administrator. The federal contract opportunity involves furnishing all labor, materials, and equipment to completely renovate seven restrooms over 80 days, complying with manufacturer, code, and VA standards while minimizing medical center disruptions. It specifies normal work hours and processes for authorization of additional hours.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C25021B0041 Amendment 0006.pdf | ||
| 36C25021B0041 Amendment 0005.pdf | ||
| 36C25021B0041 Amendment 0004.pdf | ||
| 36C25021B0041 Amendment 0003 - RFI 001 Response.docx | DOCX document | |
| RFI 001 Response - Bid Opening Location.pdf | ||
| 36C25021B0041 Amendment 0002.pdf | ||
| 36C25021B0041 Amendment 0001.pdf | ||
| Specifications.pdf | ||
| RFI Form Solicitation.doc | DOC document | |
| 36C25021B0041.pdf | ||
| Wage Determination.pdf | ||
| Drawings.pdf |
Show all 12
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .