S02 Solicitation Attachment Four EMR Form.docx
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- Solicitation number
- 36C24823R0098
About this file
This document contains an EMR form for bidders to complete and submit with proposals for federal contracts. The form requests safety and health information including OSHA recordable incident rates for the past four years, copies of OSHA forms 300 and 300A, the bidder's NAICS code for the work, who administers its safety program, and its experience modification rates for the past three years. An experience modification rate above 1.0 would disqualify the contractor. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs Veterans Health Administration to design, build, and install ceiling lifts at the Lake Nona VA Medical Center. Bidders are directed to the attached solicitation for additional requirement details.
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SOLICITATION ATTACHMENT FOUR (4) – EMR FORM
EMR 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 |
| 2019 |
| 2020 |
| 2021 |
| 2022 |
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): _____________
File details come from the government source that posted it. Updated .