S02 Contractor EMR Certification Form - 553-22-231.pdf
PDF 107 KB Posted
- Attached to
- Z1DA--Replace Fire Pump-Controller and ATS5 553-22-231 Federal contract opportunity
- Solicitation number
- 36C25024B0054
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Form related to Solicitation 36C25024B0054 to replace the fire pump controller and automatic transfer switch at the Department of Veterans Affairs Medical Center in Detroit, Michigan.
The form requests the prospective contractor to provide information about their safety record, including the number of man hours, OSHA recordable incidents, and OSHA violations over the past 3 years. The contractor must also submit their current EMR letter from their insurance carrier and identify the NAICS code for this acquisition. The purpose is to assist in determining the contractor's responsibility in accordance with Federal Acquisition Regulation (FAR) 9.104-1(e). No pricing, set-asides, or award date information is provided in this document.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| S02 Specifications - 553-22-231.pdf | ||
| 36C25024B0054_1.docx | DOCX document | |
| S02 Wage Determination - MI20240101 04 05 2024 - 553-22-231.pdf | ||
| S02 Drawings - 553-22-231.pdf | ||
| S02 RFI Form - 553-22-231.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 36C25024B0054 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)2023 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 .