S02 - Attachment 12 - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24825R0114
About this file
The document is an Employee Modification Rate (EMR) Form for contractors to complete and submit with their proposal for a VA construction project. The form requires bidders to provide detailed safety and health information, including OSHA 300 forms documenting workplace incidents over the past three years, with specific metrics such as man-hours, workplace injury cases, and Days Away, Restricted, or Transferred (DART) rates. Contractors must disclose their NAICS code, safety program administrator, and Experience Modification Rate, with disqualifying criteria including an EMR greater than 1.0 or multiple serious, willful, or repeat OSHA violations.
This form is associated with Solicitation No. 36C24825R0114, a Department of Veterans Affairs project to replace the roof on Building 7 at the Miami VA Medical Center, estimated between $2-5 million. Key project details include a mandatory site visit on July 2, 2025, at 9:00 AM, and a Request for Information (RFI) deadline of July 8, 2025, at 1:00 PM EST. The solicitation is set aside for Service-Disabled Veteran-Owned Small Businesses (SDVOSB), with contractors required to be registered in SAM.gov and verified in SBA's VetCert program. Proposals must be submitted electronically to specified VA contracting personnel.
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Text version
EMR 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 |
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 .