S02 - Attachment 4 - EMR.pdf
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- Solicitation number
- 36C24825R0036
About this file
The document is an EMR (Experience Modification Rate) Form for Bidder/Offeror to complete and submit with a proposal for a federal contract. The form requires detailed safety and occupational health information, including OSHA 300 Form data for 2021-2024, covering man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Contractors must attach OSHA 300 and 300a Forms, provide their NAICS Code, identify who administers their Safety and Health Program, and disclose their Insurance Experience Modification Rate. Key disqualifying criteria include having four serious OSHA violations, one repeat violation, one willful violation, or an EMR greater than 1.0. This form is specifically part of the VA solicitation for Project 675-23-103, an update to the Lake Nona Canteen, with a projected site visit on 04/14/2025 and is intended to assess contractor safety performance and responsibility.
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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 .