Attachment IV - Contractor EMR Certification Form 610A4-25-226.pdf

This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Project 610A4-25-226. The form is a template designed to collect and assess contractor safety performance data and qualifications prior to contract award. It requires contractors to provide company contact information and complete four years of historical safety data (2021-2024) extracted from OSHA 300 Forms, including total man hours, number of cases involving days away from work or restricted activity, DART rates, and the number of serious, willful, or repeat OSHA violations. Contractors must attach copies of completed OSHA 300 and 300a Forms and provide explanations for any violations cited within the past three years.

Additional required submissions include the six-digit NAICS Code (238210 is pre-filled for this acquisition, indicating construction of buildings), identification of the individual or department administering the company's Safety and Health Program, and the company's current Insurance Experience Modification Rate (EMR). This evaluation form serves as a pre-award screening mechanism to ensure prospective contractors demonstrate acceptable safety records and compliance with occupational safety and health standards before contract execution.