Attachment 1: Experience Modification Rate Form
Updated
A PDF document (165 KB) attached to Y1DA | 521-24-102 | Renovate Wards 2K and 2B for Optometry/Ophthalmology Clinical Use, from the Department of Veterans Affairs. Due Nov 12, 2026, 1:00 PM (UTC-5).
File name: Attachment 1 - Experience Modification Rate Form.pdf
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Attachment 1
Experience Modification Rate Form
Offeror To Complete & return with response to solicitation 1. Utilizing your OSHA 300 Forms, please complete the following information: Category
2023
2024
2025
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: 4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than
The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases will be used to ensure the contractor meets Experience Modification Rate indicated in the solicitation.
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