Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25021B0073
About this file
This document contains a pre-solicitation notice and related federal contract opportunity for installation of a simulation lab at a Veterans Affairs medical center. The pre-solicitation announces the agency's intent to issue an invitation for bid on November 20, 2021 for renovation of existing space and installation of a simulation lab. The work is to be completed within 365 calendar days of notice to proceed at the John D. Dingell VAMC in Detroit, Michigan. The estimated value is between $1 million and $2 million. The awarded firm fixed price contract will have a period of performance of 365 calendar days. The NAICS code is 236220 and the small business size standard is $39.5 million. This 100% set-aside opportunity is reserved for qualified Service-Disabled Veteran Owned Small Businesses. Questions must be submitted in writing and responses will be provided in the issued solicitation available on SAM.gov on the anticipated date.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25021B0073 0002.pdf | ||
| S02 - Wage Determination 01-07-2022 - 553-16-104.pdf | ||
| S04 - PreBid Site Visit Attendance Log - 553-16-104.pdf | ||
| 36C25021B0073 0001.docx | DOCX document | |
| S02 - Wage Determination 12-17-2021 - 553-16-104.pdf | ||
| RFI Form Solicitation.doc | DOC document | |
| 36C25021B0073.docx | DOCX document | |
| Sim Lab Bid DWG VOL 1 08-23-2021.pdf | ||
| Sim Lab Bid DWG VOL 2 08-23-2021.pdf | ||
| Wage Determination MI20210101 10-29-2021.pdf | ||
| Sim Lab Bid Specifications.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 36C25021B0073 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 .