S02 AttB OSHA _ EMR Info 585-21-111 Nurse Call.pdf
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- Attached to
- Z1DA--585-21-111 Upgrade Nurse Call System at the Oscar G. Johnson VA Medical Center in Iron Mountain , MI
- Solicitation number
- 36C25223B0013
About this file
This document contains an attachment to a solicitation for upgrading a nurse call system at the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan. The solicitation requires bidding contractors to submit safety and environmental records from the past three years, including any OSHA or EPA violations. Contractors must also provide their current experience modification rate from their insurance carrier, or an equivalent rating from an alternate source if they are self-insured. Additionally, the solicitation requests the bidding company's six-digit NAICS code, administrator of their safety and health program, and insurance EMR. Relevant supporting documentation including OSHA forms and injury rates must be included. The solicitation number is 36C25223B0013 and is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 12.
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SOL 36C252230013, ATTACHMENT B
Project 585-21-111 Upgrade Nurse Call System Page 1 of 2
ADDITIONAL PRIME CONTRACTOR INFORMATION - Safety or
Environmental Violations and Experience Modification Rating
Information
Information provided below shall be applicable to Project 585-21-111 Upgrade Nurse Call.
1.) All Bidders/Offerors shall submit information pertaining to their past Safety and
Environmental record. The information must contain a certification that the bidder/offeror has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years. If such certification cannot be made, a Bidder/Offeror shall explain why and submit as much information as possible regarding the circumstances of its past safety and environmental record, including the number of EPA violations and/or the number of serious, repeat, and/or willful OSHA violations, along with a detailed description of those violations.
2.) All Bidders/Offerors shall submit information regarding their current Experience
Modification Rate (EMR). This information shall be obtained from the Bidder’s/Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead. If a Bidder/Offeror’s
EMR is above 1.0, Bidder/Offeror must submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the elevated EMR and the anticipated date the EMR may be reduced to 1.0 or below.
3.) Self-insured contractors or other contractors that cannot provide their EMR rating on insurance letterhead must obtain a rating from the National Council on Compensation
Insurance, Inc. (NCCI) by completing/submitting form ERM-6 and providing the rating on letterhead from NCCI. Note: Self-insured contractors or other contractors that cannot provide EMR rating on insurance letterhead from the states or territories of CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR shall obtain their EMR rating from their state-run worker’s compensation insurance rating bureau.
4.) If the NCCI cannot issue an EMR because the Bidder/Offeror lacks insurance history, Bidder/Offeror shall submit a letter indicating so from its insurance carrier furnished on the insurance carrier’s letterhead, and include a letter from the NCCI indicating that is has assigned
Bidder/Offeror a Unity Rating of 1.0.
5.) The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases, will be used to make an initial
Determination of Responsibility.
6.) This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for determining the responsibility of their prospective subcontractors.
SOL 36C252230013, ATTACHMENT B
Project 585-21-111 Upgrade Nurse Call System Page 2 of 2
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25223B0013 for Project
585-21-111 Upgrade Nurse Call System.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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.
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 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): ____________________________ http://www.osha.gov/pls/publications/publication.html
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