Attachment 1 - Experience Modification Rate Form.pdf
PDF 227 KB Posted
- Attached to
- 679-22-106 Replace HVAC Various Buildings Federal contract opportunity
- Solicitation number
- 36C24725R0031
About this file
This is an Experience Modification Rate (EMR) Form that must be completed and returned by offerors as part of their response to a solicitation for HVAC replacement work at VA Buildings 2 and 46.
The form requires companies to provide their contact information and safety performance data from OSHA 300 Forms for years 2022-2024, including total man-hours worked, number of cases involving days away from work or restricted activity, DART rate calculations, and any OSHA violations within the past 3 years. Companies must also report their EMR rates for the past 3 years and attach copies of OSHA 300 and 300a forms. The form specifies that four serious violations, one repeat violation, or one willful violation will disqualify a 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.
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Text version
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 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 .