S02 - Attachment_3_EMR_(MANDATORY)_(1 Page).pdf

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Z2DZ--FY22: NRM Tier 2 (PROJ: 672-22-604) DB - Replace Facility Main Feeders at San Juan VAMC.
Solicitation number
36C24822R0102
Issued by

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This document contains an attachment for a bidder/offeror to complete and submit with a proposal. It requests information on the company's safety record and insurance over the past three years. Bidders are asked to provide their NAICS code, details on OSHA 300 forms such as number of man hours and cases involving days away from work or restricted activity, DART rates, and any serious, willful, or repeat OSHA violations over the past three years. Copies of OSHA 300 and 300a forms are to be attached along with the company's experience modification rates for insurance over the past three years, with a rate over 1.0 disqualifying the contractor.

The related federal contract opportunity is solicitation number 36C24822R0102 to replace facility main feeders at the San Juan VA Medical Center for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.

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ATTACHMENT: 3

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 .