EXHIBIT D - EMR Form.pdf
PDF 103 KB Posted
- Solicitation number
- 36C25621R0093
About this file
This document contains a pre-solicitation notice and exhibit form for a federal construction contract opportunity. The Department of Veterans Affairs VISN 16 is seeking a general contractor to construct a new main entrance at the south canopy/drop-off location of the John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas. The project scope involves creating the main entrance, improving patient entry and traffic flow, installing a covered pedestrian walkway, and addressing accessibility and force protection requirements. The contract value is estimated between $5 million to $10 million, and the NAICS code is 236220. Interested firms must be verified as a Service-Disabled Veteran-Owned Small Business in the VetBiz system by the projected solicitation posting date of May 5, 2021 on beta.SAM.gov. The exhibit form requests safety, insurance, and financial information from prospective bidders to evaluate contractor qualifications and past performance.
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Other files
| File | Type | Posted |
|---|---|---|
| Attch C Wage Determination AR20210027.txt | TXT text file | |
| EXHIBIT B Past and Present Performance Questionnaire.pdf | ||
| EXHIBIT C CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx | DOCX document | |
| Attch B Construction Drawings.pdf | ||
| 36C25621R0093.docx | DOCX document | |
| Attch A Construction Specifications.pdf | ||
| EXHIBIT A PERFORMANCE RELEVANCY SURVEY.docx | DOCX document |
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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 .