S02 Contractor EMR Certification Form - 515-23-101.docx
DOCX document 29 KB Posted
- Attached to
- Z1DA--Renovate Audiology 515-23-101
- Solicitation number
- 36C25025B0019
About this file
This document is a Pre-Award Contractor Experience Modification Rate (EMR) Certification Form for Solicitation 36C25025B0019, a renovation project for the Audiology department at the VA Medical Center in Battle Creek, Michigan. The form requires contractors to provide detailed safety and workplace injury information for the past three calendar years, including total man-hours, workplace injury cases, days away/restricted work rates, and OSHA violation history.
The form requests contractors to submit supporting documentation such as OSHA 300 and 300a Forms from 2020 and a letter from their insurance carrier stating the current EMR rate. Contractors must also provide their six-digit NAICS code, identify the person administering their safety program, and disclose their company's Insurance Experience Modification Rate. This documentation is part of the Department of Veterans Affairs' assessment of contractor responsibility and safety capabilities for the renovation project, in line with federal procurement regulations.
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25025B0019 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 |
| 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.
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 .