J.06 Attachment 06 - EMR [1 Page].docx

DOCX document 14 KB Posted

Attached to
Y1DA--FY23: NRM -Tier 1 (PROJ: 573-23-800) Install Boiler Plant Stairs
Solicitation number
36C24823R0019
Issued by

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This document contains an EMR form for bidders to complete and submit with proposals for a federal contract opportunity. The form requests information on a bidder's OSHA 300 forms from 2019 to 2021 including man hours, cases involving days away from work or restricted activity, and DART rate. It also requests the bidder's NAICS code, who administers their safety and health program, and their insurance EMR for the past three years. Bidders must attach explanations for any serious, willful, or repeat OSHA violations from the past three years, as well as copies of their OSHA 300 and 300a forms.

The related federal contract opportunity is solicitation number 36C24823R0019 to install boiler plant stairs at a Veterans Affairs medical center. This is a Tier 1 small business set-aside for Service-Disabled Veteran-Owned Small Businesses. The proposal due date is November 21, 2022 at 1:30 PM. The solicitation provides a project number and states that there will be no site visit during phase 1 of the procurement.

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Other files

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S02 -SF1449 - SOLICITATION OPEN MARKET - 36C24823R0019.pdf PDF
J.09 Attachment 09 - Subcontractor Past Performance Consent Form (1 page).pdf PDF
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J.07 Attachment 07 - Letter of Commitment for Design Firm Teaming Arrangement (1 page).pdf PDF
J.02 Attachment 02 - Specifications [98 Pages].pdf PDF
J.11 Attachment 11 - Past Performance Questionnaire (4 pages).pdf PDF
J.01 Attachment 01 - Statement of work [24 Pages].docx DOCX document
J.08 Attachment 08 - Specialized Experience Form (3 pages).pdf PDF
J.10 Attachment 10 Letter of Commitment for Design Firm [1 Page].pdf PDF
J.04 Attachment 03 - Wage Determination [5 Pages].pdf PDF

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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 .