Attachment 4 - EMR.pdf
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- Solicitation number
- 36C24825R0035
About this file
This is an Experience Modification Rate (EMR) form that contractors must complete and submit with their proposals as part of a pre-award contractor evaluation process for a VA renovation project. The form requires bidders to provide detailed safety performance data using OSHA 300 Forms for the years 2022-2024, including man-hours worked, cases involving days away from work or restricted activity, DART rates, and any OSHA violations within the past 3 years.
Key qualification requirements include: contractors must not have an EMR greater than 1.0 for the past 3 years, must not have four or more serious violations, one repeat violation, or one willful OSHA violation within the last 3 years. Bidders must provide their NAICS code, identify who administers their Safety and Health Program, and submit copies of OSHA 300 and 300a Forms. The form is designed to evaluate contractors' safety performance and compliance history prior to contract award for the PM Shop renovation and aluminum canopy roof replacement project.
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form Company Name:
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category Number of man-hours (job site and office) The 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).
The number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach an 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 disqualifies the contractor): _____________
_____2022 2023 2024
File details come from the government source that posted it. Updated .