S02 EMR Certification Form - 553-22-201.pdf
PDF 107 KB Posted
- Attached to
- Z1DA--Replace Vacuum Pumps 553-22-201 - 0002 Federal contract opportunity
- Solicitation number
- 36C25025B0016
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form required for Solicitation 36C25025B0016 from the Department of Veterans Affairs. The form requests safety performance data from prospective contractors to assess their responsibility in accordance with FAR requirements.
The form requires contractors to provide detailed safety statistics for the past three calendar years (2021-2024), including man-hours worked, OSHA incidents involving days away from work, DART rates, and any OSHA violations. Contractors must submit their 2024 OSHA 300 and 300a Forms, a letter from their insurance carrier stating their current EMR rate, applicable NAICS code, and information about their Safety and Health Program administrator. This form is part of a solicitation for replacing vacuum pumps at the John D. Dingell VA Medical Center in Detroit, Michigan, which is a 100% SDVOSB set-aside with an estimated value between $500,000 and $1,000,000.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| RFI Responses - 553-22-201.docx | DOCX document | |
| 36C25025B0016 0002.docx | DOCX document | |
| 36C25025B0016 0001.docx | DOCX document | |
| Bid Schedule 553-22-201 Replace Vacuum Pumps.pdf | ||
| S04 - Pre Bid Site Visit Attendance Log - 553-22-201.doc.pdf | ||
| S02 RFI Form - 553-22-201.pdf | ||
| S02 Wage Determination - MI20250101 02 21 2025 - 553-22-201.pdf | ||
| S02 Final Specifications - 553-22-201.pdf | ||
| S02 FInal Drawings - 553-22-201.pdf | ||
| 36C25025B0016_1.docx | DOCX document |
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 36C25025B0016 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 2021 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)2024 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 .