Contractor EMR Certification Form - 515-15-117.docx
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- Solicitation number
- 36C25025B0047
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form used to evaluate contractor responsibility for Solicitation 36C25025B0047, a Department of Veterans Affairs project titled "Z1DA--Replace Electrical Primary Distribution 515-15-117." The form requests safety and workers' compensation data from prospective contractors to assess their organizational capability, experience, and safety programs in accordance with FAR 9.104-1(e) responsibility standards.
Contractors must provide three years of OSHA safety data (2022-2024) including total man hours, DART rates (days away, restricted, or transferred cases), and any serious, willful, or repeat OSHA violations with explanations. Supporting documentation requirements include copies of 2020 OSHA 300 and 300a Forms and a current EMR rate letter from the contractor's insurance carrier. Additionally, contractors must supply their six-digit NAICS code, identify the person responsible for administering the company's Safety and Health Program, and provide their current Insurance Experience Modification Rate. This form serves as a template and information-gathering tool rather than specifying particular products or services, as the actual scope is addressed elsewhere in the solicitation materials.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25025B0047 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2022 |
| 2023 |
| 2024 |
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.
2. Please attach copies of the following documents: a) 2020 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b) Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .