EMR Certification Form - 506-21-202.pdf
PDF 107 KB Posted
- Attached to
- Z1DA--Replace Roofing B-1W 506-21-202 Federal contract opportunity
- Solicitation number
- 36C25024B0033
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Form related to Solicitation 36C25024B0033 for the Department of Veterans Affairs. The form requests information about the contractor's safety record, including the number of man-hours, OSHA 300 data, and any OSHA violations over the past three years. The contractor is required to attach their current OSHA 300 and 300a forms, as well as a letter from their insurance carrier stating their current EMR rate. The contractor must also provide their 6-digit NAICS code and the name and title of the person who administers their safety and health program. The purpose of this information is to assist in making an initial determination of the contractor's responsibility in accordance with FAR 9.104-1(e).
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| CONTRACT 36C25024C0116 PROJECT 506-21-202 AWARDED.pdf | ||
| Pre Bid Site Visit Attendance Log - 506-21-202.pdf | ||
| 36C25024B0033 0004 - 506-21-202.pdf | ||
| 36C25024B0033 0003 - 506-21-202.pdf | ||
| 36C25024B0033 0002 - 506-21-202.pdf | ||
| 36C25024B0033 0001 - 506-21-202.pdf | ||
| RFIs Answered - 506-21-202.pdf | ||
| Wage Determination MI20240100 Apr 5 2024 - 506-21-202.pdf | ||
| Pre-Bid Site Visit Agenda signed - 506-21-202.pdf | ||
| ATTENDANCE LOG - Pre-Bid Site Visit - 506-21-202.pdf | ||
| RFI Form - 506-21-202.doc | DOC document | |
| Specifications Mar 27 - 506-21-202.pdf | ||
| Wage Determination MI20240100 Jan 19 2024 - 506-21-202.pdf | ||
| Drawings - 506-21-202.pdf | ||
| 36C25024B0033_4.docx | DOCX document | |
| Drawing 01W-AS140 - 506-21-202.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 36C25024B0033 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 2020 2021 2022 2023
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)2023 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): ______ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .