Contractor EMR Certification Form - 553-21-100.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C25026B0024
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form used by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 for Solicitation 36C25026B0024, a remodeling project to convert A2South to a Cancer Clinic (Project Code 553-21-100). The form is designed to evaluate contractor responsibility by assessing safety performance and experience modification rates in accordance with FAR 9.104-1(e) requirements.
Contractors must provide comprehensive safety and loss history data covering the past three calendar years (2022, 2024), including total man hours, number of OSHA recordable cases involving days away from work or restricted activity (DART rate calculation), and documentation of any serious, willful, or repeat OSHA violations with explanations. Supporting documentation requirements include copies of OSHA 300 and 300A forms from 2020, a letter from the contractor's insurance carrier stating the current EMR rate, and identification of the six-digit NAICS code applicable to the acquisition. Contractors must also identify the individual responsible for administering the company's Safety and Health Program and provide their current Insurance Experience Modification Rate. This information serves as a pre-award evaluation tool to determine whether prospective contractors possess necessary organizational controls, experience, and safety programs required for project execution.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C25026B0024 0006.docx | DOCX document | |
| 36C25026B0024 0005.docx | DOCX document | |
| S06 36C25026B0024 0004 - 553-21-100.docx | DOCX document | |
| S06 36C25026B0024 0003 - 553-21-100.pdf | ||
| S06 Addendum 2 - 553-21-100.pdf | ||
| S06 RFI Responses 3 - 553-21-100.pdf | ||
| 36C25026B0024 0003.docx | DOCX document | |
| S06 BSC Product Data - 553-21-100.pdf | ||
| RFI Responses 2 - 553-21-100.pdf | ||
| S06 Addendum 1 - 553-21-100.pdf | ||
| 36C25026B0024 0002.docx | DOCX document | |
| Pre-Bid Site Visit Attendance Log 553-21-100.pdf | ||
| RFI Responses - 553-21-100.pdf | ||
| 36C25026B0024 0001.docx | DOCX document | |
| S02 36C25026B0024 - 553-21-100.pdf | ||
| Specs Vol2 - 553-21-100.pdf | ||
| Specs Vol1 - 553-21-100.pdf | ||
| Wage Determination MI20260101 - 01-02-2026 - 553-21-100.pdf | ||
| Drawings - 553-21-100.pdf | ||
| RFI Form - 553-21-100.doc | DOC document |
Show all 20
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 36C25025B0040 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 |
| 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.
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 .