Contractor EMR Certification Form.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C24922B0014
About this file
This solicitation is for roof replacement services at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The contractor shall furnish all labor, materials, equipment and supervision necessary to remove the existing ballasted roof system on Building 204 totaling approximately 13,400 square feet and replace it with a new insulated 60 mil EDPM roofing system matching the products and workmanship of an earlier phase. The project includes base and deductive bid items with performance periods of 150 and 120 days respectively from notice to proceed. The solicitation is a 100% set-aside for service-disabled veteran-owned small businesses. The estimated value is between $1 million to $2 million. The wage determination, Davis-Bacon Act rates apply. The deadline for questions is March 3, 2022. Bids are due by the date specified in block 13A of the SF1442. The successful bidder must meet experience, safety, insurance and other responsibility requirements and comply with all applicable regulations including VA privacy training and E-Verify registration.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24922B0014 Amendment 0003.pdf | ||
| 36C24922B0014 Questions and Answers 02.docx | DOCX document | |
| 36C24922B0014 0002.docx | DOCX document | |
| 36C24922B0014_1.pdf | ||
| 36C24922B0014 0001.docx | DOCX document | |
| 36C24922B0014 Purpose.docx | DOCX document | |
| 36C24922B0014_1.docx | DOCX document | |
| DRAWING 621-21-115.pdf | ||
| Attachment 1- B204 Roof Phase 1.pdf | ||
| Specs - 621-21-115.pdf | ||
| WD TN20220111 dated 01-07-2022.pdf | ||
| RFI Form.docx | DOCX document | |
| Roof Exist Cond Photos - 621-21-115 Bldg 204.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 36C24922B0014 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 |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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: 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.
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 .