Attachment 05 Experience Modification Rate Form.pdf
PDF 165 KB Posted
- Attached to
- Z1DA--534-CSI-714 / CARDIAC CATHETERIZATION LAB #1 SITE PREP - CONSTRUCTION / (VA-26-00042281)
- Solicitation number
- 36C24726B0003
About this file
This is an Experience Modification Rate Form template that offerors must complete and submit with their response to a federal solicitation. The form requires companies to provide basic identifying information including company name, address, telephone, email, and primary contact.
The form mandates submission of specific occupational safety and health data from OSHA 300 Forms covering three calendar years (2023, 2024, and 2025). Offerors must report the number of man hours worked at jobsite and office locations; the number of cases involving days away from work, restricted activity, or both (from OSHA 300 Columns H and I); the Days Away, Restricted, or Transferred (DART) rate calculated using the formula (number of cases × 200,000 ÷ number of man hours); and the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations. Offerors must also provide their six-digit North American Industrial Classification System (NAICS) code, identify the administrator of their Safety and Health Program, and report their Insurance Experience Modification Rate (EMR) for the past three years. The form specifies that an EMR greater than 1.0 may disqualify an offeror. Supporting documentation including copies of OSHA 300 and 300a Forms must be attached. The government will cross-reference submitted information with OSHA and EPA online inspection history databases to verify the contractor meets the Experience Modification Rate threshold stated 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 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. (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 may disqualify the offeror): _______________________________________________________________
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
File details come from the government source that posted it. Updated .