Attachment 1 - Experience Modification Rate Form.pdf
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- Solicitation number
- 36C24726R0134
About this file
This document is an Experience Modification Rate (EMR) Form template that offerors must complete and submit with their response to a federal solicitation.
The form requires companies to provide identifying information including company name, address, telephone, email, and primary contact. Offerors must complete a detailed safety and health history table covering three years (2023-2025) that documents total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity per 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 total man hours. Companies must also report the number of serious, willful, or repeat violations from OSHA within the last three years with explanations attached; contractors with four serious violations, one repeat violation, or one willful violation are disqualified. Additionally, offerors must provide their six-digit NAICS code for the acquisition, identify who administers their Safety and Health Program, and report their company's Insurance Experience Modification Rate (EMR) for the past three years. An EMR greater than 1.0 may result in disqualification. Offerors must attach copies of their OSHA 300 and 300a Forms. The government will use the submitted information along with data from OSHA and EPA online inspection history databases to verify contractor compliance with 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 .