S02 Contractor EMR Certification Form - 515-22-101.docx
DOCX document 28 KB Posted
- Attached to
- Z1DA--Renovate Restrooms 515-22-101
- Solicitation number
- 36C25024B0034
About this file
This document is a pre-award form for contractors to provide experience modification rate (EMR) information in response to solicitation 36C25024B0034 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 for renovating restrooms at location 515-22-101. The form requests company identifying information and OSHA recordable incident rates for the past three years, including total man hours worked, cases involving days away from work, restricted activity or job transfer, and days away from work rate. Contractors must also provide their current EMR insurance rate from their carrier and attach copies of the past three years of OSHA 300 and 300A forms. The six-digit NAICS code for the work and the name and title of the company's safety program administrator are additionally requested. This pre-award form is to assist the agency in determining contractor responsibility in accordance with FAR requirements.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25024B0034 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| 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.
2. Please attach copies of the following documents: a) 2020 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b) Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .