Contractor EMR Certification Form 2023_HVAC.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--HVAC Controls Replacement Project 652-25-100 Federal contract opportunity
- Solicitation number
- 36C24625B0011
About this file
This is a pre-award Experience Modification Rate (EMR) certification form required for bidders responding to Solicitation 36C24625B0011 for an HVAC Controls Replacement Project at the Richmond VA Medical Center. The form requires contractors to provide detailed safety performance data including OSHA 300 information for 2022-2024, current EMR rates, and DART (Days Away, Restricted, or Transferred) rates. Contractors must submit copies of their 2023 OSHA 300/300a forms and insurance carrier documentation of their current EMR rate.
The associated solicitation is a 100% Service-Disabled Veteran-Owned Small Business (SDVOSB) set-aside with an estimated construction magnitude between $250,000 and $500,000. The project falls under NAICS code 238220 (Plumbing, Heating and Air Conditioning Contractors) with a size standard of $19.0 million. The Department of Veterans Affairs Veterans Health Administration Network 6 is managing this sealed bid procurement under FAR Part 14.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Site Visit Sign-in Sheet 2.13.25.pdf | ||
| 36C24625B0011 0002.docx | DOCX document | |
| 36C24625B0011 0001.docx | DOCX document | |
| S02_36C24625B0011_1.pdf | ||
| 852.219-75.docx | DOCX document | |
| 36C24625B0011_1.docx | DOCX document | |
| 652-25-100 Construction Drawings.pdf | ||
| 652-25-100 Specifications.pdf | ||
| 52.219-28.docx | DOCX document | |
| Wage Determination VA20250155 1.10.25.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 bid applicable to Solicitation 36C24625B0011 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 |
| 2022 |
| 2023 |
| 2024 |
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)2023 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 .