S02 - Attachment 5 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Reconfigure Lake Nona Dental Lab
- Solicitation number
- 36C24822R0084
About this file
This document contains a pre-award evaluation form and details of a related federal contract opportunity for dental laboratory renovations at a Veterans Affairs medical center. The pre-award form requests safety and insurance information from bidders, including OSHA recordable incident rates for the past three years, primary NAICS code, safety program administrator, and experience modification rates. The related solicitation seeks design-build services to reconfigure an existing dental laboratory, involving demolition of cabinets and workstations, installation of new casework and equipment, construction of walls and electrical work, and other upgrades. The opportunity is open to licensed general contractors in Florida and issued by VA Veterans Integrated Service Network 8.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 |
| 2018 |
| 2019 |
| 2020 |
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 .