Contractor EMR Certification Form - 506-26-202.docx
DOCX document 16 KB Posted
- Attached to
- Z1DA--Tuckpointing 506-26-202 Federal contract opportunity
- Solicitation number
- 36C25026B0019
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Certification Form required for Solicitation 36C25026B0019, a tuckpointing project for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form is designed to evaluate contractor responsibility and safety qualifications in accordance with FAR 9.104-1(e) by collecting detailed information about the contractor's occupational safety and health record and experience modification rate.
Contractors must provide three calendar years of OSHA data including total man hours worked, number of cases involving days away from work or restricted activity, and the DART rate calculation. Additionally, contractors are required to submit copies of OSHA 300 and 300A forms for 2020, a letter from their insurance carrier stating the current EMR rate, and identify the person responsible for administering their company's safety and health program. The form also requests the six-digit NAICS code applicable to the acquisition and the contractor's Insurance Experience Modification Rate. Any serious, willful, or repeat OSHA violations from the past three years must be documented with explanations attached.
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|---|---|---|
| 36C25026B0019 0003.docx | DOCX document | |
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| 506-26-202 Tuckpointing - bid project specification manual R2 2026 02 20.pdf | ||
| Drawing 28-A.201 North - South Elevation - amendment 1.pdf | ||
| Drawing 01W-a.200 East - West elevation - amendment 1.pdf | ||
| 36C25026B0019 0002.docx | DOCX document | |
| S04 506-26-202 Tuckpointing Sign in sheet 2026 02 10.pdf | ||
| S04 Pre-Bid Site Visit Agenda - 506-26-202 Tuckpointing - lrr.pdf | ||
| 36C25026B0019 0001.docx | DOCX document | |
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| Specifications Manual R1 - 506-26-202 Tuckpointing.pdf | ||
| Drawings - 506-26-202 Tuckpoint.pdf | ||
| 36C25026B0019_2.docx | DOCX document | |
| RFI Form - 506-26-202.doc | DOC document | |
| ATTACHMENT VAAR 852.219-75 DEVIATION Jan 2023 LIMITATIONS OF SUBCONTRACTING COMPLIANCE CERTIFICATION.docx | DOCX document |
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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 36C25026B0019 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 |
| 2023 |
| 2024 |
| 2025 |
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 .