Contractor EMR Certification Form.pdf
PDF 109 KB Posted
- Attached to
- Z1DA--Project# 626A4-20-103- Improve Security York Campus Federal contract opportunity
- Solicitation number
- 36C24925B0007
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925R0055, designed to assess a contractor's safety performance and environmental record. The form requires detailed OSHA reporting information, including man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations for the years 2022-2024. Contractors must attach their OSHA 300 and 300a Forms and provide their six-digit North American Industrial Classification System (NAICS) Code, which in this case is 236220 for Commercial and Institutional Building Construction.
The form also requests information about the company's Safety and Health Program administrator and the Insurance Experience Modification Rate (EMR). Contractors are expected to comprehensively document their safety performance, including the number of workplace incidents, severity of injuries, and any violations from OSHA within the past three years. This evaluation is likely part of a pre-qualification process to assess a contractor's safety record and potential risk before awarding a federal contract.
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| UEI _ TAX ID.docx | DOCX document | |
| P07_Wage Determination.docx | DOCX document | |
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| RFI Form.docx | DOCX document | |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24925R0055
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.
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: 236220 – Commercial and Institutional Building Construction
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .