Attach 5 EMR.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24825R0034
About this file
This is an Experience Modification Rate (EMR) form template that contractors must complete and submit with their proposals for a Hemodialysis facility refresh project at Bay Pines VA Hospital. The form requires bidders to provide three years of safety data (2021-2023) from their OSHA 300 Forms, including total man hours worked, cases involving days away from work or restricted activity, and DART (Days Away, Restricted, or Transferred) rates. Contractors must also report any OSHA violations, with four serious violations, one repeat violation, or one willful violation resulting in disqualification.
The form requires submission of OSHA 300 and 300a Forms, the company's NAICS code, safety program administrator information, and EMR rates for the past three years, with rates above 1.0 resulting in disqualification. This is a pre-award evaluation document focused on contractor safety performance metrics that will be used to evaluate bidders for the VA construction project.
View the file
Other files
Show all 20
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PROPOSAL Attach 4 Pre-Award Contractor Evaluation Form Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
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. 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): _____________
File details come from the government source that posted it. Updated .