Attachment 1 - Experience Modification Rate Form.pdf
PDF 228 KB Posted
- Attached to
- 521-23-121 | Renovate SPS Phase 2 Federal contract opportunity
- Solicitation number
- 36C24726R0011
About this file
This document is an Experience Modification Rate Form, Attachment 1 to Request for Proposal (RFP) No. 36C24726R0011. The form requires offerors to complete detailed safety and workplace injury information using OSHA 300 Forms for the years 2022-2024. Specifically, contractors must provide data on man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any OSHA violations. The form stipulates that four serious violations, one repeat violation, or one willful violation will disqualify the contractor. Contractors must also attach copies of OSHA 300 and 300a Forms and provide their Insurance Experience Modification Rate (EMR) for the past three years. The government will use this information, along with data from OSHA and EPA online inspection history databases, to evaluate contractor safety performance and compliance for the solicitation.
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Text version
Attachment 1 - RFP No. 36C24726R0011 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 .