Attachment 1 Experience Modification Rate Form.pdf
PDF 164 KB Posted
- Attached to
- Y1DA--521-21-106 | Medical Gas Systems
- Solicitation number
- 36C24725R0020
About this file
This is an Experience Modification Rate (EMR) Form that offerors must complete and return with their response to RFP 36C24725R0020. The form requires contractors to provide their company information and safety performance data, including man-hours worked, OSHA incident statistics, and EMR rates for the years 2022-2024.
The form specifically requests data from OSHA 300 Forms regarding: number of man hours (jobsite and office), cases involving days away from work or restricted activity, DART rate calculations, and any serious/willful/repeat OSHA violations within the last 3 years. Contractors must attach copies of OSHA 300 and 300a Forms, as well as provide their company's Insurance EMR for the past 3 years. The form notes that four serious violations, one repeat violation, or one willful violation will disqualify the contractor. This information, along with data from government systems like OSHA and EPA inspection databases, will be used to evaluate if contractors meet the EMR requirements specified in the solicitation.
View the file
Other files
Show all 29
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 - RFP 36C24725R0020 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 .