S02 - Attachment 04 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Install Garage Cameras at Lake Nona VAMC
- Solicitation number
- 36C24823R0050
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for installation of parking garage cameras at a Veterans Affairs medical center.
The pre-award contractor evaluation form requests safety and health information from bidders, including OSHA 300 and 300a forms from the previous three years detailing man hours, injury cases, and incident rates. It also asks for the bidder's NAICS code, safety program administrator, and experience modification rates for insurance over the past three years.
The related federal contract opportunity is a solicitation to provide professional construction services to install parking garage cameras at the Lake Nona VA Medical Center in Orlando, Florida. The solicitation provides the number, issuing agency as the Veterans Health Administration, and gives a brief description of the required scope of work to construct the camera installation project as defined in the request for proposal.
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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 .