S02 - Attachment - 4 - EMR (1 Page).docx

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Attached to
Tier 2 NRM (PROJ: 546-16-113) BB - Replace Ductwork and Piping and Conduct Duct Cleaning Building 1
Solicitation number
36C24823R0125
Issued by

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This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity. The form requests information from bidders including number of man-hours and OSHA cases for the past three years, NAICS code, safety program administrator, and experience modification rates. Bidders must also attach OSHA forms and explain any serious, willful, or repeat violations. The related solicitation is from the Department of Veterans Affairs for ductwork and piping replacement and duct cleaning at Building 1 at a project site. Price proposals are due by June 29, 2023 at 1:00PM. The pre-award form will be used to evaluate bidders on safety criteria for the contract award.

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Other files

File Type Posted
S02 - Attachment - 2 - Specialized Experience From.pdf PDF
S02 - Attachment - 9 - Specifications (1).pdf PDF
S02 - Attachment - 5 - Letter of Commitment.pdf PDF
S02 - Attachment - 3 - Past Performance Forms.pdf PDF
S02 - Attachment - 7 - VAAR 52.219-75 VA Notice of Limitations on Subcontracting - Certificate of Compliance for Services and Construction (NOV 2022).pdf PDF
S02 - Attachment 8 - Drawings.pdf PDF
S02 - Solicitation 36C24823R0125 Ductwork and Piping.pdf PDF
S02 - Attachment - 6 - Base Offer Price Breakdown (1 Page).xlsx XLSX spreadsheet
S02 - Attachment 1 - Wage Determination.pdf PDF

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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 .