Contractor EMR Certification Form .docx
DOCX document 15 KB Posted
- Attached to
- J041--Building 22 Chiller Replacement 655-22-201 Federal contract opportunity
- Solicitation number
- 36C25022B0056
About this file
This document contains a pre-award contractor experience modification rate form and details of a federal contract opportunity for chiller replacement services at a VA medical center. The form requests contact information and safety performance history over the past three years, including OSHA recordable incident rates and violations. It also requires the contractor's NAICS code and insurance EMR for the work. The related federal contract opportunity is to replace two aging chiller units and chilled water pumps serving Building 22 at the Aleda E. Lutz VA Medical Center in Saginaw, Michigan. The new chillers will be installed on the existing roof platform with chilled water piping running back to upgraded pumps in the second floor mechanical room. The Department of Veterans Affairs VISN 10 is the contracting agency.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Notice of Award 36C25022C0274.pdf | ||
| 36C25022B0056 Amendment 0001.pdf | ||
| Wage Determination MI20220100.pdf | ||
| 36C25022B0056.pdf | ||
| Project 655-22-201 Scope of Work.pdf | ||
| RFI Form Solicitation.doc | DOC document | |
| Project 655-22-201 Drawings.pdf | ||
| Project 655-22-201 Specifications.pdf |
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 36C25022B0056 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 |
| 2019 |
| 2020 |
| 2021 |
| 2022 |
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 .