S02_RFP Attachment_EMR.docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--FY23: NRM-Tier 1 (PROJ: 673-21-148) BB - Renovate Bldg 1 - 5 South to Private Patient Rooms
- Solicitation number
- 36C24823R0199
About this file
This document contains a pre-award contractor evaluation form and details for a related federal contract opportunity. The form requests information from bidders including number of man hours, OSHA cases, DART rate, violations, NAICS code, safety program administrator, and experience modification rate over three years. Bidders must also attach OSHA forms and explain any violations. The related federal contract opportunity is from the Department of Veterans Affairs for renovating Building 1-5 South at a VA medical center to convert to private patient rooms. The solicitation number and additional details about the project are provided.
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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. (Four serious, one repeat, or one willful disqualifies the contractor.)
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
2. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program? __________________________________
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________
File details come from the government source that posted it. Updated .