S02 - Attachment 4 - EMR .docx
DOCX document 14 KB Posted
- Attached to
- Address Roof at Viera
- Solicitation number
- 36C24823R0136
About this file
This document contains a pre-award evaluation form and details of a federal contract opportunity for roof repair services. The evaluation form requests safety and insurance information from bidders, including OSHA recordable incident rates for the past three years, NAICS code, safety program administrator, and experience modification rates. Bidders must attach documentation of OSHA forms and have an EMR of 1.0 or below to qualify.
The related federal contract opportunity is solicitation number 36C24823R0136 from the Department of Veterans Affairs for roof coating and repair services. The contractor will install a new roof coating system compatible with existing modified bitumen and acrylic roofing to address leaks. The roof area is approximately 150,000 square feet.
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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 .