Attachment 1 - Experience Modification Rate Form.pdf
PDF 165 KB Posted
- Attached to
- Y1DA--679-21-102 | Correct Failing Sanitary Sewer, Water Main, and Fire Protection Deficiencies
- Solicitation number
- 36C24725R0044
About this file
This is an Experience Modification Rate (EMR) Form that offerors must complete and return with their response to RFP 36C24725R0044. The form requires contractors to provide three years of safety performance data (2022-2024) including total man-hours worked, number of cases involving days away from work or restricted activity (from OSHA 300 form), DART rate calculations, and any OSHA violations. Four serious violations, one repeat violation, or one willful violation will disqualify the contractor.
The form requires submission of OSHA 300 and 300a forms as attachments, along with the company's Insurance EMR rates for the past three years. The Department of Veterans Affairs will use this information, along with data from government systems like OSHA and EPA inspection databases, to verify the contractor meets the Experience Modification Rate requirements specified in the solicitation. This form appears to be Attachment 1 for a project involving sanitary sewer, water main, and fire protection deficiency corrections.
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Attachment 1 - RFP 36C24725R0044 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 .