Attachment 1 - Experience Modification Rate Form.pdf
PDF 248 KB Posted
- Solicitation number
- 36C24725R0046
About this file
This is an Experience Modification Rate (EMR) Form required as Attachment 1 for a VA solicitation regarding an Inpatient Pharmacy IV Compounding Room project. The form requires offerors to provide detailed safety and accident information spanning 2022-2024, including total man-hours worked, cases involving days away from work or restricted activity (from OSHA 300 forms), DART rates (calculated as number of cases x 200,000/man hours), and any OSHA violations within the past three years.
The form requires submission of OSHA 300 and 300a forms as attachments and the company's EMR rates for the past three years. Notable disqualification criteria include having four serious violations, one repeat violation, or one willful OSHA violation. The government will verify submitted information against OSHA and EPA online inspection databases to ensure contractors meet the EMR requirements specified in the solicitation.
View the file
Other files
Show all 22
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
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 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. (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 .