S02 - ATTACHMENT 6 - EMR (1 PAGE).DOCX
DOCX document 14 KB Posted
- Attached to
- Secure Medical Gas Farm
- Solicitation number
- 36C24822R0089
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for a secure medical gas farm. The evaluation form requests company information including North American Industry Classification System code, OSHA recordable incident rates for the past three years, workers' compensation insurance experience modification rate, and safety program administration. Supporting documents including OSHA 300 and 300A forms must be attached.
The related federal contract opportunity is a construction contract to be negotiated for complete construction services for a secure medical gas farm. The solicitation number is provided. A site visit is scheduled for May 3rd and requests for information are due by May 6th. Price proposals are due by May 27th. The contract will be awarded 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 4- PRICE MATRIX.XLSX | XLSX spreadsheet | |
| S02 - ATTACHMENT 2 _ WAGE DETERMINATION.TXT | TXT text file | |
| S02 - ATTACHMENT 3 - CONTRACT PROGRESS SCHEDULE.DOCX | DOCX document | |
| 36C24822R0089 Secure Medical Gas Farm.pdf | ||
| 0 0 Bound Design Analysis for Reference.pdf | ||
| S02 - ATTACHMENT 7 - EXPERIENCE INFORMATION SHEET.DOCX | DOCX document | |
| S02 - ATTACHMENT 5 PAST PERFORMANCE FORMS.PDF | ||
| S02 - ATTACHMENT 1 - PROJECT LOCATION.PDF |
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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 .