Attachment 1 - Experience Modification Rate Form.pdf
PDF 205 KB Posted
- Attached to
- Replace Repair Roofs for Buildings 4, 15, 90, 93
- Solicitation number
- 36C24725R0018
About this file
This is an Experience Modification Rate (EMR) Form that contractors must complete and return with their response to the solicitation for the VA roof repair project. The form requires contractors to provide three years of safety performance data (2021-2023) including total man-hours worked, number of cases involving days away from work or restricted activity (from OSHA 300 form), DART rate calculations, and any OSHA violations.
The form requires submission of OSHA 300 and 300a forms as attachments and the company's EMR rates for the past three years. Notable disqualification criteria includes having four serious violations, one repeat violation, or one willful OSHA violation within the last three years. The information provided will be verified against government systems including OSHA and EPA inspection databases to ensure contractors meet the EMR requirements specified in the solicitation.
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Text version
Attachment 1 Experience Modification Rate Form
Offeror To Complete & return with response to solicitation
Company Name: ______________________________________________________________________
Address: _____________________________________________________________________________
Telephone: _______________________ Email: _____________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 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. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years :
The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases will be used to ensure the contractor meets Experience Modification Rate indicated in the solicitation.
http://www.osha.gov/pls/publications/publication.html VHAV07PowerJ1 Cross-Out
File details come from the government source that posted it. Updated .