S02 - Contractor EMR Certification Form - 553-21-106.pdf
PDF 213 KB Posted
- Attached to
- Z1DA--Insulate Exterior Walls, Replace Windows 553-21-106 Federal contract opportunity
- Solicitation number
- 36C25023B0024
About this file
This pre-award form requests contractor safety information from offerors for solicitation 36C25023B0024 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 to insulate exterior walls and replace windows. Offerors must provide their company name and contact information, OSHA 300 and 300A forms from the past three years with man-hours, injury cases, and DART rates, any serious OSHA violations in the past three years with explanations, current insurance EMR rate from their carrier, NAICS code for this work, safety program administrator name and title, and current insurance EMR. By requesting this information, the agency intends to make an initial responsibility determination for any potential awardee in accordance with FAR 9.104-1(e) on organization, experience, controls, skills, and applicable safety programs for materials and services.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25023B0024 0002.pdf | ||
| 553-21-106 Pre-Bid Site Visit Agenda_.pdf | ||
| 553-21-106 Pre-bid Site Visit Attendance Log.pdf | ||
| 36C25023B0024 0001.pdf | ||
| 36C25023B0024 0001.docx | DOCX document | |
| _36C25023B0024_.pdf | ||
| Drawings Addendum 1 Notes.pdf | ||
| Drawings - Project 553-21-106.pdf | ||
| Specifications - Project 553-21-106 - Volume II.pdf | ||
| Specifications - Project 553-21-106 - Volume I.pdf | ||
| S02 - RFI Form 553-21-106.pdf | ||
| WD GDN MI20230101 Mod 2 -02-24-2023 - Building - Wayne County.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 36C25023B0024 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 .