S02 ATTACHMENT C EMR (1 PAGE).docx
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- Attached to
- Z1DA--FY23: NRM-Tier 1 (Proj:546-16-103) B/B Replace Pneumatics with Direct Digital Control
- Solicitation number
- 36C24823R0032
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity. The evaluation form requests safety and health information from bidders, including OSHA recordable incident rates for the past three years, NAICS code, safety program administrator, and experience modification rates. Bidders must also attach copies of recent OSHA forms and explanations for any serious, willful, or repeat violations.
The related federal contract opportunity is a 100% SDVOSB set-aside to replace digital pneumatics with direct digital controls at a Department of Veterans Affairs site. A pre-bid site visit is scheduled for November 22nd, 2022 and questions are due by November 29th. Proposals for the project located at 1201 NW 16th Street in Miami, Florida are due December 12th, 2022.
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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 .