S02 - Attachment 12 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Cancellation Notice* Z1DA--PROJECT 546-24-119, Bid-Build (BB) Replace Roof in Building 7 at Miami VAHCS
- Solicitation number
- 36C24824R0156
About this file
This document is an EMR (Experience Modification Rate) form that bidders/offerors must complete and submit with their proposals for the federal contract opportunity. The form requires the bidder to provide information about their OSHA 300 forms, including the number of man-hours, days away/restricted/transferred cases, DART rate, and any OSHA violations over the past 3 years. The bidder must also provide their 6-digit NAICS code, the administrator of their safety and health program, and their EMR for the past 3 years (an EMR greater than 1.0 disqualifies the contractor).
The related federal contract opportunity is for the "Replace Roof in Building 7 at Miami VAHCS, Project 546-24-119" solicitation, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8. The contract is for construction services to replace the roof of Building 7 at the Miami VA Healthcare System facility.
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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 |
| 2021 |
| 2022 |
| 2023 |
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 .