J.08 Attachment 08 - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24822R0148
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for renovating common area restrooms at a Veterans Affairs medical center. The pre-award form requests information on the bidding contractor's safety record over the past three years, including OSHA 300 forms, days away from work or job transfer rates, serious violations, and insurance experience modification rates. The federal contract opportunity is set aside for Service-Disabled Veteran-Owned Small Businesses for renovations at a VA medical center in Lake City, Florida, with a site visit scheduled for August 15th and proposals due by August 31st, 2022. The pre-award form and contract details provide relevant safety, insurance, and responsibility information to evaluate contractors for the restroom renovation project at the specified VA location.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| WAGE DETERMINATION.pdf | ||
| PRICE SCHEDULE.docx | DOCX document | |
| J.11 Attachment 11 - VHA Supplemental Contract Requirements for Combatting COVID-19 (2 pages).docx | DOCX document | |
| J.02 Attachment 02 - Drawings.pdf | ||
| J.03 Attachment 03 - Specifications.pdf | ||
| J.10 Attachment 10 - Specialized Experience Form [pages].pdf | ||
| J.01 Attachment 01 - Statement of Work.docx | DOCX document | |
| J.07 Attachment 07 - Past Performance Questionnaire.docx | DOCX document | |
| J.06 Attachment 06 -Price Matric.xls | XLS spreadsheet | |
| J.05 Attachment 05 - LOS Certification.doc | DOC document | |
| J.09 Attachment 09 - Experience Information Sheet.docx | DOCX document | |
| S02 - SOLICITATION - BB OPEN MARKET.pdf | ||
| J.04 Attachment 04 - Wage Determination.pdf |
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 .