Contractor EMR Certification Form - 553-21-204.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C25026B0037
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form required for Solicitation 36C25026B0037, a Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 project to relocate sewer-pump station controls (Z1DA--Relocate Sewer-Pump Station No 3 Controls 553-21-204). The form is used to assist in making initial responsibility determinations for potential awardees in accordance with FAR 9.104-1(e) regarding necessary organization, experience, accounting and operational controls, and technical skills including safety programs.
Contractors must provide company information including name, address, contact details, and the name and title of the person administering the company's Safety and Health Program. The form requires submission of OSHA 300 and 300a Forms for 2020 and the past three calendar years (2023, 2024, 2025), with detailed data on man hours, cases involving days away from work or restricted activity, calculated DART rates, and any serious, willful, or repeat OSHA violations with explanations. Contractors must also submit a letter from their insurance carrier stating the current EMR rate, provide their six-digit NAICS Code for the acquisition, and disclose their company's Insurance Experience Modification Rate.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25026B0037 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 .