Attachment C EMR.pdf
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- Solicitation number
- 36C24826R0057
About this file
This is a Pre-Award Contractor Evaluation Form (EMR Form) that bidders and offerors must complete and submit with their proposals to demonstrate safety and health compliance.
The form requires contractors to provide company information including name, address, telephone, fax, email, and primary contact. Contractors must complete a four-year safety data table (2021-2024) utilizing OSHA 300 Forms, reporting total man hours, number of cases involving days away from work or restricted activity (Column H and I data), the calculated Days Away, Restricted, or Transferred (DART) Rate, and the number of serious, willful, or repeat OSHA violations. Contractors must attach copies of OSHA 300 and 300a Forms, which are accessible through the OSHA publications search page. Additionally, contractors must provide their six-digit North American Industrial Classification System (NAICS) Code, identify the individual who administers the company's Safety and Health Program, and submit their Insurance Experience Modification Rate (EMR) for the past three years. Disqualifying factors include four or more serious violations, one or more repeat violations, one or more willful violations from OSHA within the last three years, or an EMR greater than 1.0.
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Text version
EMR FORM
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 2021 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): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .