Attachment 9 EMR Form.pdf
PDF 77 KB Posted
- Solicitation number
- 36C24825R0168
About this file
This document is an EMR (Experience Modification Rate) Form for Bidder/Offeror to complete and submit with a proposal. The form requires contractors to provide detailed safety and health performance metrics, including OSHA-related information for the years 2022-2024. Key requirements include documenting man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. The form mandates that contractors attach OSHA 300 and 300a Forms, provide their six-digit NAICS Code, identify who administers their Safety and Health Program, and disclose their Insurance Experience Modification Rate. Contractors with more than four serious violations, one repeat violation, or one willful violation will be disqualified, and an EMR greater than 1.0 will also result in disqualification.
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Text version
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 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. (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 .