EMR 1 page.pdf
PDF 279 KB Posted
- Solicitation number
- 36C24826Q0128
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Form, designed to collect comprehensive safety and environmental performance data from potential contractors. The form requires detailed information across three years (2023-2025), including total man-hours worked, workplace injury/incident rates, days away from work or restricted activity (DART Rate), and any serious, willful, or repeat violations from OSHA or EPA. Companies must also provide their OSHA 300 and 300a Forms, identify who administers their Safety and Health Program, and demonstrate an Insurance Experience Modification Rate (EMR) of 1 or less, which indicates a strong safety record and lower workplace risk.
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Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
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 or any EPA violations within the last 3 years. Please attach explanation for any violations.
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. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________ http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .