S02 - Attachment 07 - Experience Modification Rate (EMR) (1 page).docx
DOCX document 14 KB Posted
- Attached to
- Z2DA--Correct Tunnel Water Protection Federal contract opportunity
- Solicitation number
- 36C24822R0156
About this file
This document contains a form for bidders to complete regarding their experience modification rate for a federal construction services project. The form requests the bidder provide their North American Industry Classification System code, details of their OSHA 300 forms from 2019 to 2021 including man hours, days away from work cases, and DART rate. The bidder must also provide their insurance experience modification rate for the past three years, which must be less than or equal to 1.0, as well as explanations for any serious, willful, or repeat OSHA violations. The related federal contract opportunity is for correct tunnel water protection project number 573-18-604 located at the Gainesville VA Medical Center. A site visit is scheduled for August 15, 2022 at 10:00 am at the specified address.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| S02 - Attachment 09 - Past Performance Survey (3 pages).docx | DOCX document | |
| S02 - Attachment 02 - Specifications (462 pages).docx | DOCX document | |
| S02 - Attachment 10 - Letter of Commitment Key Subcontractors (1 page).pdf | ||
| S02 - Attachment 08 - Past Performance Questionnaire (3 pages).docx | DOCX document | |
| S02 - Attachment 06 - Price Matrix (1 page).xlsx | XLSX spreadsheet | |
| S02 - Attachment 01 - Drawings (26 pages).pdf | ||
| S02 - Attachment 11 - Subcontractor Past Performance Consent Form (1 page).docx | DOCX document | |
| S02 - Attachment 05 - Wage Determination (5 pages).pdf | ||
| S02 - Attachment 04 - VHA Supplemental Contract Requirements for Combatting COVID-19 (2 pages).docx | DOCX document | |
| S02 - Attachment 03 - LOS Certification (1 page).docx | DOCX document | |
| 36C24822R0156 (BB Correct Tunnel).docx | DOCX document |
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PRICE 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 .