S02 - Attachment 5 - EMR (1 Page).docx

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Attached to
Correct Trace Steam, Condensate, and Piping Deficiencies
Solicitation number
36C24823R0059
Issued by

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This document contains an EMR form for bidders to complete and submit with proposals for a federal construction contract. The form requests the bidder's company name, address, contact information, NAICS code, OSHA recordable incident rates for the past three years including man hours worked and DART rates, any serious OSHA violations in the past three years, and the bidder's experience modification rates for the past three years. Bidders must also attach copies of their OSHA 300 and 300A forms from the past three years.

The related federal contract opportunity is seeking fixed-price construction services to correct trace steam, condensate equipment, and piping at the Miami VA Medical Center. A site visit is scheduled for November 30th, 2022 at 10:00 AM. Requests for information are due December 9th, 2022 and price proposals are due December 20th, 2022. The solicitation was issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.

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Other files

File Type Posted
S02 - Attachment 3 - Wage Determination.pdf PDF
S02 - Attachment 2 - Study.pdf PDF
S02 - Attachment 8- Price Matrix.xlsx XLSX spreadsheet
S02 - Solicitation 36C24823R0059 _ Water Trace _ Condensate Repair.pdf PDF
S02 - Attachment 6 Past Performance Forms.pdf PDF
S02 - Attachment 1 - Drawings.pdf PDF
S02 - Attachment 7 - Specialized Experience From.pdf PDF
S02 - Attachment 4 Limitations of Subcontracting.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
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 .