Contractor EMR Certification Form - 506-25-502.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Correct SPS Ceiling System Finding 506-25-502 Federal contract opportunity
- Solicitation number
- 36C25025B0012
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form associated with Solicitation 36C25024B0027 for the Department of Veterans Affairs. The form requires contractors to provide safety performance data and documentation to assist in determining contractor responsibility under FAR 9.104-1(e).
The form requests detailed safety information including OSHA 300 data for 2021-2023 (man hours, cases involving days away from work, DART rates, and OSHA violations), copies of OSHA 300 and 300a Forms from 2020, current EMR rate documentation from the insurance carrier, applicable NAICS code, and safety program administrator information. This appears to be a standard pre-award responsibility determination form focused on contractor safety performance metrics and programs.
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| 36C25025B0012 0002.docx | DOCX document | |
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| Wage Determination MI20240100 01292025.pdf | ||
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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 offer applicable to Solicitation 36C25024B0027 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) 2020 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 .