J.08 Attachment 08 - EMR.docx

DOCX document 14 KB Posted

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Y1DA-- Project NO. : 573-18-601 BB - Renovate 4B for Hemodialysis
Solicitation number
36C24822R0158
Issued by

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This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for renovating space to accommodate a hemodialysis unit. The pre-award form requests information on the bidding company's safety record over the past three years, including OSHA 300 forms, number of man hours, days away from work cases, and serious violations. It also requires the company's NAICS code and details on its safety program administration and experience modification rate. The federal contract opportunity is a solicitation to renovate space at a Veterans Affairs medical center to accommodate a hemodialysis unit. It specifies a site visit date and location, a proposal due date of August 31, 2022, and that the requirement is set aside for Service-Disabled Veteran-Owned Small Businesses. The agency is identified as the Veterans Health Administration within the Department of Veterans Affairs.

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Other files

File Type Posted
J.04 Attachment 04 - Wage Determination.pdf PDF
S02 - SOLICITATION 36C24822R0158- RENOVATE 4B HEMODIALYSIS.pdf PDF
J.10 Attachment 10 - Specialized Experience Form.pdf PDF
J.07 Attachment 07 - Past Performance Questionnaire.docx DOCX document
J.09 Attachment 09 - Experience Information Sheet.docx DOCX document
J.05 Attachment 05 - Los Certification Solicitation Version.doc DOC document
J.01 Attachment 01 - Statement of Work.pdf PDF
J.03 Attachment 03 - Specifications.pdf PDF
J.06 Attachment 06 – Price Metric.xls XLS spreadsheet
J. 11 Attachment 11 - VHA Supplemental Contract Requirements for Combatting COVID-19 (2 pages).docx DOCX document
J.02 Attachment 02 - Drawing.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 .