Attachment 1 - Experience Modification Rate Form.pdf
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- Solicitation number
- 36C24725R0023
About this file
This is an Experience Modification Rate (EMR) Form template (Attachment 1) that offerors must complete and return with their response to a solicitation for replacing a sewer lift pump at VA facilities. The form requires contractors to provide three years of safety data (2022-2024) including man-hours worked, OSHA incident rates, DART rates, and any OSHA violations. Companies must submit their EMR rates for the past three years, with rates above 1.0 potentially disqualifying them.
The form requires submission of OSHA 300 and 300a forms, the company's six-digit NAICS code, and information about who administers their Safety and Health Program. Companies with four serious violations, one repeat violation, or one willful OSHA violation in the past three years are disqualified. The form notes that this information, along with data from government systems like OSHA and EPA inspection databases, will be used to verify the contractor meets 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 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. 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 .