S02 - Attachment 4 - EMR.docx
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- Solicitation number
- 36C24823R0008
About this file
This document contains a pre-award evaluation form and details of a federal contract opportunity to replace two air handling units at a Veterans Affairs medical center. The pre-award form requests company information including number of man hours, OSHA recordable incidents, DART rate, serious violations over the past three years, NAICS code, safety program administrator, and experience modification rates for the past three years. The federal contract opportunity involves removing and replacing two air handling units with new units containing HEPA filters, stack coils, minimum supply air capacities, double wall ductwork, UV lights, direct drive plenum fans with dedicated VFDs, eight-row cooling coils, and pandemic operating mode. Ancillary requirements include piping, electrical systems, duct connections, hydronic systems, insulation, louvers, roof supports, DDC controls integrated into an existing Siemens system, wind load rated curbs, roof flashing, rigging and hoisting. The work must be certified by a mechanical engineer and meet various codes and standards. The contracting agency is the Veterans Health Administration within the Department of Veterans Affairs.
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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 |
| 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 .