Contractor EMR Certification Form - 506-CSI-133 v2.docx
DOCX document 16 KB Posted
- Attached to
- Z1DA--Site Prep for D758 & D759 506-CSI-133
- Solicitation number
- 36C25026B0022
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Certification Form for Solicitation 36C25026B0022, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requires contractors to provide detailed safety and health information, including three years of OSHA-related data such as man hours, workplace injury cases, days away or restricted work rates, and OSHA violation history.
Contractors must submit supporting documentation, including OSHA 300 and 300a Forms from 2020 and a letter from their insurance carrier stating the current EMR rate. The form seeks to assess a contractor's safety program and organizational responsibility in accordance with federal acquisition regulations, specifically for a site preparation project (Z1DA--Site Prep for D758 & D759). Key submission requirements include providing the company's six-digit NAICS code, details of the safety program administrator, and the company's current Insurance Experience Modification Rate.
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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 36C25026B0022 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 |
| 2023 |
| 2024 |
| 2025 |
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 .