ATTACHMENT 9 - EMR.pdf
PDF 231 KB Posted
- Solicitation number
- 36C24825R0042
About this file
This document is an EMR (Experience Modification Rate) Form for a pre-award contractor evaluation, designed to be completed and submitted with a proposal for the VA's Lake Baldwin Electrical Distribution improvement project. The form requires bidders to provide detailed safety and performance metrics, including OSHA-related information such as man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations for the years 2021-2024.
Key evaluation criteria include submitting OSHA 300 and 300a forms, providing a six-digit NAICS code, identifying the administrator of the company's Safety and Health Program, and reporting the Insurance Experience Modification Rate. Disqualifying factors are four serious OSHA violations, one repeat violation, one willful violation, or an EMR greater than 1.0. The form is part of solicitation 36C24825R0042 for the Department of Veterans Affairs Veterans Health Administration, specifically for Veterans Integrated Service Network 8, and is associated with a project to improve electrical distribution at Lake Baldwin.
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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 .