Attachment 1 - Experience Modification Rate Form.pdf
PDF 317 KB Posted
- Attached to
- Cancelled | 508-22-104 | Upgrade PACS System
- Solicitation number
- 36C24726R0096
About this file
This is an Experience Modification Rate (EMR) Form that offerors must complete and submit with their response to RFP No. 36C24726R0096. The form serves as a template for collecting and reporting contractor safety and worker injury data to evaluate compliance with specified Experience Modification Rate requirements in the solicitation.
The form requires offerors to provide company identifying information and complete a three-year safety history table covering 2023, 2024, and 2025. Specifically, offerors must report the number of man hours worked (jobsite and office combined), the number of cases involving days away from work or restricted activity (using OSHA 300 Form Columns H and I), and calculate the Days Away, Restricted, or Transferred (DART) Rate using the standard formula of (number of cases × 200,000) divided by man hours. Additionally, offerors must disclose the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations identified; 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 and provide their company's Insurance Experience Modification Rate (EMR) for the past three years. The Government will verify this information against OSHA and EPA online inspection history databases to ensure contractor compliance with the EMR threshold specified in the solicitation.
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Attachment 1 - RFP No. 36C24726R0096 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 .