Attachment 1 - Experience Modification Rate Form.pdf
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- Attached to
- 679-19-101 Correct Critical Access and ADA Deficiencies B61 Federal contract opportunity
- Solicitation number
- 36C24726R0069
About this file
This is an Experience Modification Rate Form that offerors must complete and return with their response to RFP No. 36C24726R0069. The form requires companies to submit safety and injury data covering a three-year period (2023, 2025, and 2025) derived from OSHA 300 Forms.
Offerors must provide the following information: total man hours worked on jobsites and in offices; the number of cases involving days away from work, restricted activity, or both as reported in OSHA 300 Columns H and I; the calculated Days Away, Restricted, or Transferred (DART) Rate using the formula of (number of cases × 200,000 ÷ number of man hours); and the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations identified. The form specifies that contractors are disqualified if they have four serious violations, one repeat violation, or one willful violation. Offerors must attach copies of OSHA 300 and 300a Forms and provide their company's Insurance Experience Modification Rate (EMR) for the past three years. The government will use the submitted information along with data from 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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Attachment 1 - RFP No. 36C24726R0069 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. 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 .