ATTACHMENT 5 - EMR.pdf
PDF 231 KB Posted
- Solicitation number
- 36C24825R0025
About this file
This is an Experience Modification Rate (EMR) form that contractors must complete and submit with their proposals for the VA Lake Nona Emergency Department renovation project. The form requires bidders to provide safety and health data from their OSHA 300 Forms for years 2021-2024, including total man hours, cases involving days away from work, DART rates, and any OSHA violations. Companies must also submit their NAICS code, identify who administers their Safety and Health Program, and provide their EMR rate for the past 3 years.
The form includes specific disqualification criteria: contractors will be disqualified if they have four serious OSHA violations, one repeat violation, one willful violation, or an EMR greater than 1.0 in the past 3 years. Bidders must attach copies of their OSHA 300 and 300a Forms and provide explanations for any violations. This safety qualification form is part of the pre-award evaluation process for contract 36C24825R0025 with the Department of Veterans Affairs.
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Text version
EMR FORM
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 2021 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. 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): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .