Attachment 6 - Experience Modification Rate Form.pdf
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- Solicitation number
- 36C24724R0018
About this file
This document is an experience modification rate form to be completed and returned by offerors in response to a solicitation for construction services. The form requests information on the offeror's man hours, OSHA recordable cases, days away from work rate, and serious violations over the past three years. It also requires the offeror to provide its six-digit NAICS code, identify who administers its safety and health program, and disclose its insurance experience modification rates for the past three years. The related federal contract opportunity is for angio-CT suite upgrades at a Department of Veterans Affairs medical center, with a solicitation number of 36C24724R0018, to be awarded by Veterans Health Administration VISN 7.
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Attachment 1 Experience Modification Rate Form
Offeror To Complete & return with response to solicitation
Company Name: ______________________________________________________________________
Address: _____________________________________________________________________________
Telephone: _______________________ Email: _____________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022 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 may disqualify the offeror): _______________________________________________________________
The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases will be used to ensure the contractor meets Experience Modification Rate indicated in the solicitation.
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .