Attachment 1 - Experience Modification Rate Form.pdf
PDF 252 KB Posted
- Attached to
- Z1DA--619A4-23-106 Correct the Mechanical/Fixtures & Piping for Buildings 2, 4 & 4A (VA-26-00016382)
- Solicitation number
- 36C24726R0070
About this file
This document is an Experience Modification Rate (EMR) Form that offerors must complete and submit with their response to a federal solicitation. The form requires contractors to provide company identification information including name, address, telephone, email, and primary contact details.
The form mandates submission of specific occupational safety and health data covering a three-year period (2023-2025), including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity as documented in OSHA 300 Forms (Columns H and I), and calculated DART rates using the formula of cases multiplied by 200,000 divided by total man hours. Contractors must also disclose the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations noted; four serious violations, one repeat violation, or one willful violation will result in contractor disqualification. Offerors are required to provide their six-digit NAICS code, identify the individual or department administering the company's Safety and Health Program, and submit their company's Insurance Experience Modification Rate for the past three years, with an EMR greater than 1.0 potentially resulting in disqualification. Supporting documentation must include copies of OSHA 300 and 300a Forms accessible through the OSHA publications website. The government will cross-reference submitted information with OSHA and EPA online inspection history databases to verify the contractor meets the Experience Modification Rate requirements specified in the solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24726R0070 0003.docx | DOCX document | |
| Attachment 10 - Revised RFI Answers.docx | DOCX document | |
| Attachment 11 - Hazmat Survey Report.pdf | ||
| Attachment 10 - RFI Answers.docx | DOCX document | |
| 36C24726R0070 0002.docx | DOCX document | |
| 36C24726R0070 0001.docx | DOCX document | |
| Attachment 9 - Site Visit Attend.pdf | ||
| Attachment 5 - Wage Determinations.txt | TXT text file | |
| Attachment 6 - INVOICING.pdf | ||
| 36C24726R0070_1.docx | DOCX document | |
| Attachment 8 - Drawings FINAL.pdf | ||
| Attachment 4 - Itemized Cost Breakdown.xlsx | XLSX spreadsheet | |
| Attachment 2 - SBA Vet SB Cert Program Class Dev.pdf | ||
| Attachment 3 - PPQ.pdf | ||
| Attachment 7 - SPECS - 619A4-23-106.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 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 .