Attachment 03 - Contractor Safety and EMR - 2 Pages.docx
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- Attached to
- Z2DA--Construct New Hybrid Operating Room Federal contract opportunity
- Solicitation number
- 36C24825R0026
About this file
Attachment 03 is a pre-award contractor safety and environmental record evaluation form for a VA construction project to build a new hybrid operating room in San Juan, Puerto Rico. The document requires bidders to submit detailed safety information, including OSHA 300 Forms documenting man-hours, workplace injury cases, and days away from work rates for the past three years. Contractors must certify they have no more than three serious, one repeat, or one willful OSHA/EPA violations in the past three years, or provide a detailed explanation of any violations.
The form also mandates contractors submit their Experience Modification Rate (EMR) from their insurance carrier, with an EMR above 1.0 requiring a written explanation. Self-insured contractors must obtain an EMR rating from the National Council on Compensation Insurance (NCCI) or state worker's compensation insurance rating bureaus. The safety information, combined with government system data, will be used to determine contractor responsibility, and this requirement applies to all subcontracting tiers. Bidders must provide their NAICS code, details about their safety and health program administration, and supporting documentation.
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Solicitation Attachment 03 Safety or Environmental Violations and Experience Modification Rate (EMR)
All Bidders/Offerors shall submit information pertaining to their past Safety and Environmental record. The information must contain a certification that the bidder/offeror has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years. If such certification cannot be made, a Bidder/Offeror shall explain why and submit as much information as possible regarding the circumstances of its past safety and environmental record, including the number of EPA violations and/or the number of serious, repeat, and/or willful OSHA violations, along with a detailed description of those violations.
All Bidders/Offerors shall submit information regarding their current Experience Modification Rate (EMR). This information shall be obtained from the Bidder’s/Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead. If a Bidder/Offeror’s EMR is above 1.0, Bidder/Offeror must submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
Self-insured contractors or other contractors that cannot provide their EMR rating on insurance letterhead must obtain a rating from the National Council on Compensation Insurance, Inc. (NCCI) by completing/submitting form ERM-6 and providing the rating on letterhead from NCCI. Note: Self-insured contractors or other contractors that cannot provide EMR rating on insurance letterhead from the states or territories of CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR shall obtain their EMR rating from their state run worker’s compensation insurance rating bureau.
If the NCCI cannot issue an EMR because the Bidder/Offeror lacks insurance history, Bidder/Offeror shall submit a letter indicating so from its insurance carrier furnished on the insurance carrier’s letterhead, and include a letter from the NCCI indicating that is has assigned Bidder/Offeror a Unity Rating of 1.0.
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 make an initial Determination of Responsibility.
This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for determining the responsibility of their prospective subcontractors.
Solicitation Attachment 03 Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| 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.
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): _____________ |
Page 2 of 2 Attachment 03
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