Contractor EMR Certification Form 2023_4B.docx
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- Attached to
- Y1DA-- Improve Patient Privacy 4B Project# 652-14-106 Federal contract opportunity
- Solicitation number
- 36C24625B0006
About this file
This is a pre-award Experience Modification Rate (EMR) form required for bid submission under Solicitation 36C24625B0006 for the Improve Patient Privacy 4B Project at Richmond VA Medical Center. The form requests contractor safety performance data, including OSHA statistics for 2021-2023 (man hours, cases involving days away from work, DART rates, and OSHA violations), current EMR rate documentation from the insurance carrier, and copies of OSHA 300/300a forms.
The related solicitation is a 100% Service-Disabled Veteran Owned Small Business (SDVOSB) set-aside for a construction project valued between $5-10 million, under NAICS code 236220 (Commercial and Institutional Building Construction). The contract will be awarded through sealed bidding procedures by the Department of Veterans Affairs Veterans Health Administration Network 6 for improvements to patient privacy areas at the Richmond VA Medical Center.
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your bid applicable to Solicitation 36C24625B0006 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2021 |
| 2022 |
| 2023 |
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.
2. Please attach copies of the following documents: a)2023 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b)Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .