S02 - Attachment 04 - EMR.pdf
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- Solicitation number
- 36C24824R0147
About this file
This document is an EMR (Experience Modification Rate) form that the bidder/offeror must complete and submit with their proposal for the federal contract opportunity. The form requires the company to provide information on their OSHA 300 forms, including the number of man-hours, DART (Days Away, Restricted or Transferred) rate, and any OSHA violations within the last 3 years. The company must also provide their 6-digit NAICS code, the administrator of their safety and health program, and their EMR for the past 3 years. An EMR greater than 1.0 disqualifies the contractor. The related federal contract opportunity is a solicitation (Solicitation Number: 36C24824R0147) for the Department of Veterans Affairs to perform structural and water intrusion repairs at the Lake Baldwin VA Clinic in Orlando, Florida. The project overview, location, and site visit details are provided.
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Text version
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH 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 2021 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. (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): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .