Attachment 1 - Experience Modification Rate Form.pdf
PDF 165 KB Posted
- Attached to
- Y1DA--521-23-121 | SPS Renovation Phase 2
- Solicitation number
- 36C24725R0079
About this file
This document is an Experience Modification Rate (EMR) Form for Request for Proposal (RFP) 36C24725R0079, related to the SPS Renovation Phase 2 project at the Birmingham, AL Veterans Affairs Medical Center. The form requires potential offerors to provide detailed safety and workplace injury information for the years 2022-2024, including total man-hours worked, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violation history.
The form mandates contractors to attach OSHA 300 and 300a Forms and disclose their Insurance Experience Modification Rate. Contractors with four serious violations, one repeat violation, or one willful violation will be disqualified. The information provided will be cross-referenced with government systems like OSHA and EPA online inspection history databases to verify the contractor meets the solicitation's Experience Modification Rate requirements. This form is part of the qualification process for the Veterans Health Administration's renovation project in Birmingham, Alabama.
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Attachment 1 - RFP 36C24725R0079 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 .