S02 Contractor EMR Certification Form - 553-21-202.docx
DOCX document 16 KB Posted
- Attached to
- Z1DA--Replace Sinks and Counters 553-21-202 - Amendment 0002 Federal contract opportunity
- Solicitation number
- 36C25025B0014
About this file
The document is a Pre-Award Contractor Experience Modification Rate (EMR) Certification Form for Solicitation 36C25025B0014, which involves replacing sinks and counters at the Detroit VA Medical Center. The form requires contractors to provide detailed safety and workplace injury information for the past three calendar years, including total man-hours, workplace injury cases, days away/restricted work rates, and OSHA violation history. Contractors must submit their current EMR rate, OSHA 300 and 300a forms from 2020, and provide their six-digit NAICS code and the name of their safety program administrator.
The related federal contract opportunity is a Request for Information (RFI) issued by the Department of Veterans Affairs Veterans Health Administration for a construction project at 4646 John R Street in Detroit, Michigan. The project involves replacing sinks and counters, with the contract specialist being Leland Ruedel, contactable at Angelo.Vivio@va.gov. The solicitation emphasizes the importance of carefully reading all project documents and requires contractors to specifically reference solicitation sections when submitting questions or requests for clarification.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25025B0014 0002.docx | DOCX document | |
| S06 New ICRA rev003 - 553-21-202.pdf | ||
| S04 - Pre Bid Site Visit Attendance Log - 553-21-202.pdf | ||
| S06 553-21-202 Replace Sinks and Counters at In-Patient Rooms - SPEC ammendment 001.pdf | ||
| 36C25025B0014 0001.docx | DOCX document | |
| S02 Specifications book - 553-21-202.pdf | ||
| VAAR Class Deviation 852.222-71, Compliance with E.O. 13899.pdf | ||
| S02 Drawings - 553-21-202.pdf | ||
| S02 RFI Form - 553-21-202.doc | DOC document | |
| 36C25025B0014_1.docx | DOCX document |
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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 36C25025B0014 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 |
| 2022 |
| 2023 |
| 2024 |
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): ______
File details come from the government source that posted it. Updated .