S02 - Attach 5 - EMR (1 Page).docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24823R0091
About this file
This document contains an EMR form for bidders to complete and submit with proposals for federal contract opportunity number 36C24823R0091. The opportunity is for construction services to resolve statement of conditions deficiencies at the C.W. Bill Young VA Medical Center in Bay Pines, Florida. The NAICS code for this procurement is 236220, with a small business size standard of $39.5 million. The project magnitude is between $500,000 and $1 million. This opportunity is 100% set aside for Service-Disabled Veteran-Owned Small Businesses. Bidders must be verified by the VA Center for Verification and Evaluation prior to award. The point of contact for this project is Joseph Wingfield, who can be reached at 307-712-5769 or taramcdonald@va.gov.
View the file
Other files
Show all 12
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 Attach 4 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 .