Attachment 4 - Experience Modification Rate.pdf
PDF 77 KB Posted
- Attached to
- Upgrade Existing OR Suite for Fire Code
- Solicitation number
- 36C24825R0044
About this file
This is a Pre-Award Contractor Evaluation Form (EMR Form) that bidders/offerors must complete and submit with their proposal. The form collects safety and health-related information from contractors, including OSHA statistics for 2020-2022 such as man-hours worked, cases involving days away from work or restricted activity, DART rate calculations, and any OSHA violations. The form requires contractors to attach OSHA 300 and 300a Forms as supporting documentation.
The form includes several automatic disqualification criteria: having four serious OSHA violations, one repeat violation, or one willful violation within the last 3 years will disqualify a contractor, as will an Experience Modification Rate (EMR) greater than 1.0. Contractors must also provide their NAICS code for the acquisition and identify who administers their Safety and Health Program. This form appears to be Attachment 4 for a VA Medical Center construction project in Miami, Florida to upgrade an Operating Room Suite for fire code compliance (Solicitation #36C24825R0044).
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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 2020 2021 2022 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): _____________
File details come from the government source that posted it. Updated .