Contractor EMR Certification Form - 553-22-209.docx
DOCX document 16 KB Posted
- Attached to
- Z1DA-Upgrade TV System IFB 553-22-209 Amendment 003 Federal contract opportunity
- Solicitation number
- 36C25026B0031
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Certification Form used to assess contractor responsibility for solicitation 36C25025B0046 with the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requires prospective contractors to demonstrate necessary organizational experience, operational controls, and safety programs in accordance with FAR 9.104-1(e).
Contractors must complete the form by providing three years of OSHA-based safety data including man hours worked, DART rates (days away, restricted, or transferred cases), and serious or repeat OSHA violations for calendar years 2022 through 2024. Supporting documentation required includes copies of 2020 OSHA 300 and 300a Forms, a letter from the contractor's insurance carrier stating the current EMR rate, the six-digit NAICS code applicable to the acquisition, identification of the company's Safety and Health Program administrator, and the company's Insurance Experience Modification Rate. This information enables the government to evaluate whether the prospective awardee possesses adequate safety protocols and experience to perform the contract requirements.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25026B0031 0003.docx | DOCX document | |
| S06 36C25026B0031 0002 - 553-22-209.pdf | ||
| S06 RFI Repsonses 1 - 553-22-209.pdf | ||
| S06 RFI Repsonses 3 - 553-22-209.pdf.pdf | ||
| S06 RFI Repsonses 2 - 553-22-209.pdf | ||
| 36C25026B0031 0002.docx | DOCX document | |
| S04 - Pre Bid Site Visit Attendance Log - 553-22-209.pdf | ||
| 36C25026B0031 0001.docx | DOCX document | |
| ATTACHMENT VAAR 852.219-75 DEVIATION Jan 2023 LIMITATIONS OF SUBCONTRACTING COMPLIANCE CERTIFICATION.pdf | ||
| S02 36C25026B0031 - Upgrade TV System Network - 553-22-209.pdf | ||
| RFI Form - 553-22-209.doc | DOC document | |
| Specs - TV System Upgrade - 553-22-209.pdf | ||
| Drawings - TV System Upgrade - 553-22-209.pdf | ||
| Wage Determination - MI20260101 01-02-2026 - 553-22-209.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 36C25025B0046 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) 2020 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 .