J.07 Attachment 07 – Experience Modification Rate (EMR) [1 Page].docx

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Y1DA--FY22: NRM Tier 2 (PROJ: 573-18-600) BB - Renovate Stairwells
Solicitation number
36C24822R0188
Issued by

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This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for renovating stairwells. The pre-award form requests information on a contractor's experience modification rate over the past three years, OSHA 300 forms from 2019 to 2021 detailing man hours, injury cases, and DART rates, as well as explanations for any serious, willful, or repeat OSHA violations. The federal contract opportunity is solicitation number 36C24822R0188 for the Department of Veterans Affairs to renovate stairwells at project number 573-18-600. Proposals are due by November 28, 2022. An organized site visit has been scheduled for November 3, 2022 at 10:00 AM at the address provided.

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EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PRICE PROPOSAL

Pre-Award Contractor Evaluation Form Company Name: ______________________________________________

Address: _____________________________________________________

Telephone: ______________________ Fax: ________________________

Email: _______________________________________________________

Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

Category
2019
2020
2021

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. (Four serious, one repeat, or one willful disqualifies the contractor.)

Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.

2. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________

3. Who administers your company’s Safety and Health Program? __________________________________

4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________

File details come from the government source that posted it. Updated .