Contractor_EMR_Certification_Form.docx
DOCX document 16 KB Posted
- Attached to
- Correct Fire Damper Deficiencies 583-19-501
- Solicitation number
- 36C25019B0008
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36C25019B0008 Contractor EMR Certification Form.docx
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25019B0008:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2015 |
| 2016 |
| 2017 |
| 2018 |
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 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):
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