ATTACHMENT 5 - EXPERIENCE MODIFICATION RATE FORM.docx
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- Solicitation number
- 36C24726R0026
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This is an Experience Modification Rate (EMR) Form that offerors must complete and submit with their proposals for the VISN 7 Construction MATOC, a multiple award task order contract for construction services at Veterans Affairs medical facilities under Veterans Integrated Service Network 7.
The form requires offerors to provide comprehensive past safety and environmental records covering three years (2023-2025), including OSHA 300 form data detailing man hours, cases involving days away from work or restricted activity, and the Days Away, Restricted, or Transferred (DART) rate calculated using the standard formula. Offerors must also report any serious, willful, or repeat OSHA violations from the preceding three years, with disqualification occurring if the contractor has four serious violations, one repeat violation, or one willful violation. Additional submission requirements include copies of OSHA 300 and 300A forms, the company's six-digit NAICS code for the acquisition, identification of the safety and health program administrator, and the company's Insurance Experience Modification Rate (EMR) for the past three years. An EMR greater than 1.0 may result in offeror disqualification. Offerors must provide basic company information including name, address, telephone, email, and primary contact details on the form.
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Attachment 5 Past Safety and Environmental Record Offeror To Complete & Submit with Proposal
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
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.)
2. 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.
3. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. Who administers your company’s Safety and Health Program? __________________________________
5. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 may disqualify the offeror): _____________
File details come from the government source that posted it. Updated .