Project 553-20-204 Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25021B0011
About this file
This document contains a pre-solicitation notice and related pre-award forms for a construction project to renovate a pharmacy at the VA Medical Center in Detroit, Michigan. The construction project, number 553-20-204, will renovate approximately 832 square feet of existing pharmacy storage and sterile compounding space to comply with the latest USP 797/800 requirements. Interested contractors must complete the pre-award forms and submit supporting documentation including OSHA 300 forms from the past three years and details of any OSHA violations. The estimated value of the firm fixed price construction contract is between $500,000 and $1,000,000, with an anticipated award within 120 days of bid receipt and a 210 day performance period. The solicitation will be issued on June 30, 2020 via SAM.gov and responses are due as specified within the solicitation. The NAICS code for this opportunity is 236220 and it is set aside for small businesses.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25021B0011 0003.docx | DOCX document | |
| S04 - ATTENDANCE LOG - 553-20-204.pdf | ||
| 36C25021B0011 0002.docx | DOCX document | |
| 553-20-204 RFI 01 VA Response.pdf | ||
| 553-20-204 Drawings - Pharmacy .pdf | ||
| 36C25021B0011 0001.docx | DOCX document | |
| 553-20-204 Drawings.pdf | ||
| Project 553-20-204 -WAGE Determination MI20200101 rev1-29-21.txt | TXT text file | |
| Proejct 553-20-204 Pre-BID instructions.docx | DOCX document | |
| Project 553-20-204 Specifications Vol. 2 pharmacy.pdf | ||
| Project 553-20-204 - Specifications Vol. 1 pharmacy.pdf | ||
| RFI Form 553-20-204.docx | DOCX document | |
| 36C25021B0011.docx | DOCX document |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25020B0045 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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.
2. Please attach copies of the following documents: 2019 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .