S02 - Attachment - 4 - EMR (1 Page).docx
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- Solicitation number
- 36C24823R0123
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for upgrading the HVAC system in Building 44 at a Veterans Affairs medical center. The evaluation form requests information on the contractor's number of man hours, OSHA recordable cases, DART rate for the past three years, any serious violations, NAICS code, safety program administrator, and experience modification rate. It must be completed and submitted with proposals. The federal contract opportunity is a solicitation to upgrade the HVAC system in the Building 44 utility plant. A site visit will take place on April 24, 2023 and requests for information are due by May 1st. The contracting agency is the Department of Veterans Affairs Veterans Health Administration VISN 8.
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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 |
| 2020 |
| 2021 |
| 2022 |
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 .