S02 - Solicitation Attachment Five - EMR Form.docx
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- Solicitation number
- 36C24823R0183
About this file
This document contains an EMR form for bidders to complete and submit with proposals for federal contracts. The form requests safety and health information including OSHA 300 and 300a forms for the past four years, NAICS code, safety program administrator, and experience modification rates. Bidders must have an EMR of 1.0 or less for the past three years. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs for site preparation for MRI replacements at Lake Nona for $675,000. Bidders must submit the completed EMR form to be considered for this contract.
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S02 – Solicitation Attachment Five (5) – EMR Form
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 |
| 2019 |
| 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 .