S02 EMR Sheet 2025.pdf
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- Solicitation number
- 36C26125R0047
About this file
This document is a Safety & Environmental Record and Experience Modification Rate (EMR) certification form from VA Health Administration Directive 7715. The form requires contractors bidding on a federal contract to provide detailed safety compliance information, specifically:
- Contractors must self-certify they have no more than three serious, one repeat, or one willful OSHA/EPA violations in the past three years, and maintain an Experience Modification Rate (EMR) of 1.0 or less. The form includes a table for documenting OSHA and EPA violations from 2022-2025, with a requirement to attach explanations for any violations. Contractors must also submit a signed letter from their insurance carrier documenting their current EMR, with additional explanation required if the EMR exceeds 1.0.
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Text version
PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY &
ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION
RATE (EMR):
Contractor Certification Regarding Project:
To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.
All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.
1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.
2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offerors’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
2022 2023 2024 2025 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.)
Number of violations from EPA within the last 3 years. Please attach explanation for any violations.
Company’s Current Insurance Experience Modification Rate (EMR) =
(Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)
Signature:
Print Name:
PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR):
File details come from the government source that posted it. Updated .