S02 - Solicitation Attachment Three (3) - EMR Form.pdf

PDF 145 KB Posted

Attached to
Y1DB--D/B PROJECT 675-24-151 - Create New Prosthetics Lab at Viera
Solicitation number
36C24824R0053
Issued by

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This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity. The form requests information from bidders on their OSHA 300 forms, NAICS code, safety program administration, and insurance experience modification rates over three years. Bidders must also attach explanations for any serious, willful, or repeat OSHA violations, as well as copies of OSHA 300 and 300a forms. The related federal contract opportunity is solicitation number 36C24824R0053 from the Department of Veterans Affairs to create a new prosthetics lab at a Veterans Health Administration facility. Additional details are provided in attachments to the solicitation.

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S06 -Amendment 0002 Attachment Six (6).pdf PDF
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S02 - Solicitation Attachment Five (5) -Experience Information Sheet.pdf PDF
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S02 - Solicitation Attachment Four (4) - Past Performance Questionnaire.docx DOCX document
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EMR FORM

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 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. (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): _____________ http://www.osha.gov/pls/publications/publication.html

File details come from the government source that posted it. Updated .