Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Attached to
- AWARDED 553-18-203 Renovate Dental Clinic
- Solicitation number
- 250
About this file
This document contains a pre-award contractor experience modification rate form and details of a related federal contract opportunity for renovation of a dental clinic at a VA medical center. The form requests contractors to provide experience modification rate data from OSHA 300 forms for the past three years, including man hours, injury cases, and DART rates. It also requires copies of 2019 OSHA 300 forms, the current EMR rate letter from the contractor's insurance carrier, the NAICS code for the work, safety program administration information, and the contractor's insurance EMR. The related solicitation is for renovation of the Second Floor Dental Clinic at the John D. Dingell VA Medical Center in Detroit, Michigan, requiring all necessary labor, equipment, tools, and supplies to deliver a complete and functional dental clinic within 365 days of notice to proceed, during normal business hours.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C250 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 .