EMR Form.pdf
PDF 103 KB Posted
- Attached to
- B170 1E Patio Courtyard Repairs Federal contract opportunity
- Solicitation number
- 36C25622R0087
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for patio courtyard repairs. The evaluation form requests company information and safety records, including OSHA forms from the past four years, insurance experience modification rates, and NAICS codes. Eligible contractors must have experience modification rates not exceeding 1.0. The federal contract opportunity is with the Department of Veterans Affairs for repairs to the Building 170 1E Courtyard/Patio in North Little Rock, Arkansas. The contractor will be responsible for all management, labor, equipment, materials, insurance, permits, and services necessary to complete the removal and replacement work defined in the Statement of Work.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Site Visit Instructions EJT NLR.pdf | ||
| FInal SOW 598-22-131.pdf | ||
| 36C25622R0087.pdf | ||
| Specifications.pdf | ||
| SF24-16d.pdf |
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Text version
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2017 2018 2019 2020 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. (Four serious, one repeat, or one willful disqualifies the contractor.)
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .