S02 - Attachment 5 - EMR.pdf
PDF 231 KB Posted
- Attached to
- BB Renovate Lake Nona Building 1 Women's Health
- Solicitation number
- 36C24825R0058
About this file
The document is an EMR (Experience Modification Rate) Form for contractors to complete and submit with their proposal for the VA solicitation 36C24825R0058. The form requires detailed safety and health information, including OSHA 300 Forms data for 2021-2024, covering man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Contractors must provide their six-digit NAICS Code, details about their Safety and Health Program administrator, and their company's Insurance Experience Modification Rate for the past three years.
Key evaluation criteria include disqualifying factors such as an EMR greater than 1.0, four serious OSHA violations, one repeat violation, or one willful violation. Contractors must attach copies of OSHA 300 and 300a Forms and provide a comprehensive overview of their workplace safety performance. This form is part of the solicitation for the Department of Veterans Affairs' project to renovate approximately 8,272 square feet of administrative space for the Lake Nona Women's Health Clinic at the Orlando Veterans Affairs Healthcare System facility.
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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 .