Attachment 1 - Experience Modification Rate Form.pdf
PDF 165 KB Posted
- Attached to
- 508-26-152 | Bus Duct Replacement Federal contract opportunity
- Solicitation number
- 36C24726R0058
About this file
This is an Experience Modification Rate Form that offerors must complete and return with their response to a federal solicitation. The form requires submission of company identification information including name, address, telephone, email, and primary contact.
The form requests detailed safety and occupational health data covering a three-year period (2023-2025) derived from OSHA 300 Forms, including total man hours worked at jobsites and offices, number of cases involving days away from work or restricted activity, and calculation of the Days Away, Restricted, or Transferred (DART) Rate using the formula of (number of cases × 200,000) divided by total man hours. Offerors must also report the number of serious, willful, or repeat OSHA violations within the past three years with explanations attached; contractors with four serious violations, one repeat violation, or one willful violation are disqualified. Additionally, offerors must provide their six-digit NAICS code, identify the administrator of their company's Safety and Health Program, and supply their Insurance Experience Modification Rate (EMR) for the past three years. An EMR greater than 1.0 may result in disqualification. Copies of OSHA 300 and 300a Forms must be attached. The government will cross-reference this submitted information with OSHA and EPA online inspection history databases to verify that the contractor meets the Experience Modification Rate requirements specified 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 .