ATTACHMENT D - EMR.pdf

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DESIGN-BUILD (DB) CONSTRUCTION: Project 675-26-100 - Refresh Lake Baldwin Pharmacy Finishes
Solicitation number
36C24825R0169
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This document is an EMR (Experience Modification Rate) Form, a Pre-Award Contractor Evaluation Form designed for bidders/offerors to complete and submit with their proposal. The form requires detailed safety and health performance information, including OSHA-related metrics for the years 2021-2024. Contractors must provide comprehensive data such as total man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violation history. Key disqualifying criteria include having an EMR greater than 1.0, four serious OSHA violations, one repeat violation, or one willful violation. Bidders are also required to attach OSHA 300 and 300a Forms, provide their six-digit NAICS Code, identify who administers their Safety and Health Program, and list their Insurance Experience Modification Rate.

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Other files

File Type Posted
ATTACHMENT A - LAKE BALDWIN SITE PLAN.pdf PDF
ATTACHMENT G - Past Performance Questionnaire.docx DOCX document
ATTACHMENT F - Base Offer Price Breakdown.xlsx XLSX spreadsheet
ATTACHMENT H - Limitation of Subcontracting Certificate.pdf PDF
S02 - 36C24825R0169.pdf PDF
ATTACHMENT B - NEW LAKE BALDWIN SITE PLAN-SURVEY-1-13-15.pdf PDF
ATTACHMENT C - Wage Determination.pdf PDF
ATTACHMENT E - Specialized Experience Form.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 .