Contractor EMR Certification Form .docx
DOCX document 15 KB Posted
- Attached to
- 506-21-103 Modernize Short Stay Federal contract opportunity
- Solicitation number
- 36C25025B0008
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) form required for Solicitation 36C25025B0008, a Department of Veterans Affairs project to modernize a Short Stay Clinic. The form requests detailed safety performance information from prospective contractors, including OSHA incident data from 2020-2023, current EMR rates, and documentation of safety programs.
The form requires contractors to submit specific documentation including OSHA 300/300a Forms, insurance carrier EMR verification, NAICS code information, and safety program administrator details. This information is being collected to assess contractor responsibility under FAR 9.104-1(e), specifically evaluating safety performance and operational controls for the renovation project which includes patient rooms, specialty procedure rooms, HVAC system upgrades, and security system improvements.
View the file
Other files for this federal contract opportunity
Show all 40
On GovTribe
Work with this file on GovTribe
- 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 36C25025B0008 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 .