Contractor EMR Certification Form.docx
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- Solicitation number
- 36C24923B0013
About this file
This solicitation is for roof replacement services at two buildings located at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The solicitation requests bids to replace the lower roofs of Buildings 160 and 77. The North American Industry Classification System code for this project is 238160. This opportunity is set aside 100% for Service-Disabled Veteran Owned Small Businesses. The bid submission deadline is June 26, 2023 at 1:00PM Central Time.
The solicitation requires bidders to complete forms providing safety and environmental compliance histories as well as current insurance ratings. Performance and payment bonds may be required for awards over $150,000. The selected contractor must also comply with all applicable federal acquisition regulations and VA policies regarding records management, privacy, security, and contractor performance evaluations.
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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 36C24923B0013 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: 2022 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
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 .