S02 - Contractor EMR Certification Form - 553-19-103.pdf
PDF 191 KB Posted
- Attached to
- Z1DA--Replace Boiler Control System 553-19-103 Federal contract opportunity
- Solicitation number
- 36C25023B0068
About this file
This document is a pre-award contractor experience modification rate form related to solicitation number 36C25023B0068 to replace a boiler control system for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requests contact information and safety history for the past three years, including OSHA 300 and 300a forms, current EMR rate from insurance carrier, NAICS code, and safety program administrator. It aims to determine responsibility for potential awardees in accordance with FAR 9.104-1(e).
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25023B0068 0001_.pdf | ||
| Breeching_Drawing.pdf | ||
| 553-19-103 Pre-Bid Site Visit Agenda_.pdf | ||
| 553-19-103_Addendum_No1_Drawings_09-11-2023.pdf | ||
| 553-19-103-Breeching Photo.png | PNG image | |
| 553-19-103_Addendum_No1_Narrative_09-11-2023.pdf | ||
| 553-19-103-Pre-bid Site-visit Sign-in Sheet.pdf | ||
| _36C25023B0068_.pdf | ||
| WD DOL GDN MI20230101 - 08-04-2023 Mod 4 - Construction Type - Building - Wayne County - MI.pdf | ||
| P03-Brand Name Only J-A Hilti -Firestopping-553-19-103 -.pdf | ||
| Drawings - 533-19-103 Replace Boiler Control System.pdf | ||
| S02 - RFI Form 553-19-103.pdf | ||
| Specifications - 533-19-103 Replace Boiler Control System.pdf | ||
| P03-Brand Name Only J-A Siemens -HVAC controls- 553-19-103 -.pdf |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25023B0068 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
Category 2020 2021 2022 2023
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.
2. Please attach copies of the following documents: a)2020 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b)Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .