J.06 Attachment 06 - EMR [1 Page].docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24823R0026
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for renovation work. The pre-award form requests safety information including OSHA recordable incident rates for the past three years, NAICS code, safety program administration details, and experience modification rates. Contractors must submit the completed form with proposals.
The federal contract opportunity is a solicitation to renovate room A180 at a Veterans Affairs medical center to accommodate a DEXA system. Proposals are due by November 20, 2022. This is a set-aside for Service-Disabled Veteran-Owned Small Businesses. The work includes design-build services for the renovation with the location given as VISN 8.
View the file
Other files
Show all 13
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
EMR 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 |
| 2019 |
| 2020 |
| 2021 |
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): _____________
File details come from the government source that posted it. Updated .