Attachment 1 - Experience Modification Rate Form.pdf
PDF 205 KB Posted
- Solicitation number
- 36C24725R0015
About this file
This is an Experience Modification Rate (EMR) Form that contractors must complete and return with their response to solicitation 36C24725R0015 for a VA project to renovate nutrition, food service, and freezers.
The form requires contractors to provide three years of safety data (2021-2023) from their OSHA 300 Forms, including total man hours worked, number of cases involving days away from work or restricted activity, DART rate calculations, and any OSHA violations. Contractors must also submit their EMR rates for the past three years and attach copies of OSHA 300 and 300a Forms. The form specifies that four serious violations, one repeat violation, or one willful violation will disqualify a contractor. The government will use this information along with OSHA and EPA inspection history databases to verify the contractor meets the EMR requirements specified in the solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24725C0057_1 Award Notice.pdf | ||
| 36C24725R0015 0003.pdf | ||
| 2025-02-03_229004_AE002.pdf | ||
| 36C24725R0015 0002.pdf | ||
| 09672360 RES 6A.pdf | ||
| RFIS Responses.xlsx | XLSX spreadsheet | |
| 36C24725R0015 0001.pdf | ||
| 36C24725R0015.docx | DOCX document | |
| Attachment 5 - DBA Wages GA20240305 11-15-2024.pdf | ||
| Attachment 3 - Past Performance Questionnaire -PPQ.docx | DOCX document | |
| Attachment 6 - INVOICING.docx | DOCX document | |
| Attachment 4 - Itemized Cost Breakdown.xlsx | XLSX spreadsheet | |
| Attachment 7 - WEB LINK FOR DRAWINGS AND SPECS.docx | DOCX document | |
| Attachment 2 - VAAR 852.219-75 VA Notice of Limitations on Subcontracting Jan 2023 Dev.pdf |
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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 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. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years :
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 VHAV07PowerJ1 Cross-Out
File details come from the government source that posted it. Updated .