EXHIBIT D - EMR Form.pdf
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- Solicitation number
- 36C25621R0154
About this file
This document contains a pre-solicitation notice and Exhibit D form for a federal contract opportunity to develop private and semi-private bed spaces at the Eugene J. Towbin Veterans Hospital in North Little Rock, Arkansas. The Department of Veterans Affairs plans to issue a solicitation on or around August 10, 2021 seeking a general contractor to renovate approximately 13,599 square feet of the third floor of the southern H-wing to current standards for Domiciliary Units. The contractor will be responsible for coordinating all necessary services and ensuring work complies with required drawings, specifications, and Statement of Work. The dollar value of the project is estimated between $5,000,000 to $10,000,000. Responses are due by July 15, 2021. The Exhibit D form requests company safety and health information such as OSHA recordable incident rates for evaluation purposes prior to award.
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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 .