Attachment 1 - Experience Modification Rate Form.pdf
PDF 205 KB Posted
- Attached to
- Z1DA--Project: 619-23-101 - Replace Roof Systems for Main Hospital, Building 1 Federal contract opportunity
- Solicitation number
- 36C24725R0030
About this file
This is an Experience Modification Rate (EMR) form that must be completed and returned with responses to a VA solicitation for a roof replacement project at the Central Alabama Veterans Health Care System. The form requires contractors to provide detailed safety performance data from their OSHA 300 Forms for 2021-2023, including total man-hours worked, cases involving days away from work or restricted activity, DART rates (Days Away, Restricted, or Transferred), and any OSHA violations.
The form requires contractors to attach copies of their OSHA 300 and 300a Forms and provide their company's EMR rates for the past 3 years. Notable disqualification criteria include having four serious violations, one repeat violation, or one willful OSHA violation within the last 3 years. The form indicates that this information, along with data from government systems like OSHA and EPA inspection databases, will be used to evaluate if 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 .