Contractor EMR Certification Form .docx
DOCX document 15 KB Posted
- Attached to
- 655-20-202 Atrium Renovation Bldg 22 Federal contract opportunity
- Solicitation number
- 36C25024B0058
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Form, which is being requested as part of Solicitation 36C25024B0058 for the Atrium Renovation of Building 22 at the Aleda E. Lutz VA Medical Center in Saginaw, Michigan.
The form requires the contractor to provide information about their safety performance, including the number of man-hours, OSHA recordable incidents, DART (Days Away, Restricted, or Transferred) rate, and any OSHA violations over the past three years. The contractor must also attach their OSHA 300 and 300A forms, a letter from their insurance carrier stating the current EMR rate, and identify the NAICS code and the person responsible for their safety program. The EMR rate for the contractor is also requested. This information is being collected to assist in determining the responsibility of the potential awardee in accordance with FAR 9.104-1(e).
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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 36C25024B0058 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 |
| 2020 |
| 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)2019 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 .