Contractor EMR Certification Form 2023_SPS.docx
DOCX document 15 KB Posted
- Attached to
- Z2DA--Renovate SPS OR Vertical Transport
- Solicitation number
- 36C24625B0005
About this file
This is a contractor Experience Modification Rate (EMR) certification form related to Solicitation 36C24625B0005 for the Department of Veterans Affairs' Richmond VA Medical Center project to renovate SPS OR Vertical Transport. The form requires bidders to provide detailed safety information including OSHA 300 data for 2021-2023 (man hours, cases involving days away from work, DART rates, and OSHA violations), current EMR rate documentation from their insurance carrier, NAICS code confirmation (238290 - Other Building Equipment Contractors), and details about their company's safety program administrator.
The form is part of a pre-award responsibility determination for a construction project estimated between $2-5 million that is set aside for Service-Disabled Veteran Owned Small Businesses (SDVOSB). The project will be awarded through sealed bidding procedures under FAR Part 14. The form requires contractors to submit their company details, contact information, and safety performance metrics as part of the bidding process.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24625B0005 0002.docx | DOCX document | |
| 36C24625B0005 0001.docx | DOCX document | |
| 36C24625B0005_1.docx | DOCX document | |
| Wage Determination.pdf | ||
| 852.219-75 VA NOTICE OF LIMITATIONS ON SUBCONTRACTING_CERTIFICATE OF COMPLIANCE FOR SERVICES AND CONSTRUCTION.docx | DOCX document | |
| 52.219-28 POST-AWARD SMALL BUSINESS PROGRAM REPRESENTATION.docx | DOCX document | |
| Specifications for Construction Bidding.pdf | ||
| Drawings for Bidding.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 36C24625B0005 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 |
| 2021 |
| 2022 |
| 2023 |
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 .