Contractor EMR Certification Form .docx
DOCX document 16 KB Posted
- Attached to
- 655-23-201 Energy Center Hot Water Heater
- Solicitation number
- 36C25025B0030
About this file
The document is a Pre-Award Contractor EMR Certification Form for Solicitation 36C25025B0030, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires contractors to provide detailed safety and health information, including three years of workplace safety metrics such as man-hours, OSHA recordable cases, days away from work rates, and OSHA violations. Contractors must submit supporting documentation including OSHA 300 and 300a Forms from 2019 and a letter from their insurance carrier stating the current Experience Modification Rate (EMR).
The related federal contract opportunity involves replacing the existing domestic hot water generating system at a Veterans Affairs facility. The project scope includes installing three plate and frame heat exchangers, two domestic and two heating hot water circulating pumps, a new storage tank, and expansion tank. The new equipment must integrate with the existing Johnson Controls Metasys Building Management System. The period of performance is 150 calendar days from the Notice to Proceed, and the work will be performed at Buildings 1 and 22 in the Energy Center.
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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 36C25025B0030 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 |
| 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)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 .