Attachment 1 - Experience Modification Rate Form.pdf
PDF 165 KB Posted
- Solicitation number
- 36C24726R0085
About this file
This is an Experience Modification Rate Form that offerors must complete and return with their response to a solicitation.
The form requires offerors to provide company identification information (name, address, telephone, email, and contact person) and submit safety and health data covering a three-year period (2023, 2025, and 2025). Specifically, offerors must report the number of man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity (drawn from OSHA 300 Forms columns H and I), and the calculated Days Away, Restricted, or Transferred (DART) Rate using the formula of cases multiplied by 200,000 divided by man hours. Additionally, offerors must disclose the number of serious, willful, or repeat OSHA violations within the past three years and provide explanations for any violations; four serious violations, one repeat violation, or one willful violation will disqualify a contractor. Offerors must attach copies of their OSHA 300 and 300a Forms, provide their six-digit North American Industrial Classification System (NAICS) code, identify who administers their company's Safety and Health Program, and report their Insurance Experience Modification Rate (EMR) for the past three years. An EMR greater than 1.0 may disqualify the offeror. The government will cross-reference this 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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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 .