Attachment 6 -(Exhibit C) EMR.docx
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- Solicitation number
- 36C24822R0116
About this file
This document contains an Exhibit C EMR form for bidders to complete and submit with proposals for federal contracts, along with details of a related solicitation.
The EMR form requests company information and safety data including number of man hours, OSHA recordable cases, days away from work rates, and experience modification rates over the past three years. Bidders must provide OSHA forms, NAICS codes, and safety program administration details. An experience modification rate over 1.0 will disqualify the contractor from award.
The combined synopsis/solicitation is from the Department of Veterans Affairs for repair of Roof B106 at a Veterans Health Administration facility. The solicitation number and project details are provided. The agency and location involved in the opportunity are identified.
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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 |
| 2018 |
| 2019 |
| 2020 |
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): _____________
File details come from the government source that posted it. Updated .