S02 - Attachment 3 - EMR.pdf
PDF 124 KB Posted
- Solicitation number
- 36C24825R0033
About this file
This is an Experience Modification Rate (EMR) form template that contractors must complete and submit with their proposals for a VA renovation project. The form requires bidders to provide three years of safety data (2022-2024) from their OSHA 300 Forms, including total man hours worked, cases involving days away from work or restricted activity, and DART rates. Contractors must also report any OSHA violations from the past 3 years, with disqualification occurring for four serious violations, one repeat violation, or one willful violation.
The form requires submission of OSHA 300 and 300a documentation, the company's NAICS code, safety program administrator information, and EMR rates for the past 3 years, with rates above 1.0 resulting in disqualification. This is part of the pre-award contractor evaluation process for solicitation #36C24825R0033 to renovate the Community Living Center's 1st and 2nd floors at a Veterans Affairs facility.
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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 2022 2023 2024 Number of man hours (job site and office)
The number of cases involving days away from work, restricted activity, or both (Columns 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).
The number of serious, willful, or repeat violations from OSHA within the last 3 years.
Please attach an 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 .