ATTACHMENT D - EMR.pdf

184 KB Posted

Attached to
Design-Build (DB) PROJECT: 675-25-108 DB Replace Galvanized Domestic Water Lines
Solicitation number
36C24825R0097
Issued by

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The document is an EMR (Experience Modification Rate) Form for a Pre-Award Contractor Evaluation, specifically related to a Department of Veterans Affairs project for replacing galvanized domestic water lines (Solicitation Number 36C24825R0097). The form requires bidders to provide detailed safety and workplace information, including OSHA-related metrics for the years 2021-2024, such as man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violation history.

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 (EMR). Contractors are disqualified if they have four serious violations, one repeat violation, one willful violation, or an EMR greater than 1.0. The form is designed to assess a contractor's safety performance and workplace safety record as part of the pre-award evaluation process for this VA health infrastructure project.

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Other files

File Type Posted
ATTACHMENT A - Lake Baldwin Replacement Plan rev1.pdf PDF
ATTACHMENT F - Base Offer Price Breakdown.xlsx XLSX spreadsheet
S02 Solicitation 36C24825R0097.pdf PDF
ATTACHMENT H - Limitation of Subcontracting Certificate.pdf PDF
ATTACHMENT B - NEW LAKE BALDWIN SITE PLAN-SURVEY-1-13-15.pdf PDF
ATTACHMENT G - Past Performance Questionnaire.docx DOCX document
ATTACHMENT C - Wage Determination 6.6.25.pdf PDF
ATTACHMENT E - Specialized Experience Form.pdf PDF
ATTACHMENT A - Lake Baldwin Replacement Plan rev1.pdf PDF

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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 .