Attachment 1 - Experience Modification Rate Form.pdf
PDF 161 KB Posted
- Attached to
- Y1DA--508-22-105 | 6th Floor CLC 16-Bed Bldg. C
- Solicitation number
- 36C24725R0029
About this file
This is an Experience Modification Rate (EMR) Form that contractors must complete and return with their solicitation response for a VA construction project at the 6th Floor CLC Building C. The form requires contractors to provide company information and safety performance data from their OSHA 300 Forms for years 2022-2024, including total man-hours worked, cases involving days away from work or restricted activity, DART rate calculations, and any OSHA violations within the past 3 years.
The form specifies that contractors must attach copies of their OSHA 300 and 300a Forms and provide their company's Insurance EMR for the past 3 years. Notable disqualification criteria include having four serious violations, one repeat violation, or one willful OSHA violation within the past 3 years. The government will use this information along with OSHA and EPA online inspection history databases to verify the contractor meets the EMR requirements specified in the solicitation.
View the file
Other files
Show all 27
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .