EMR Attachment - Address Retro Commissioning Items.pdf
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- Solicitation number
- 36C25026B0040
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form applicable to federal solicitation #36C25026B0040. The form is a template designed to collect contractor safety and occupational health information as part of the pre-award evaluation process.
The form requires contractors to submit company contact information and provide three years of occupational safety data (2018–2020) extracted from OSHA 300 Forms, including total man hours, number of cases involving days away from work or restricted activity, and calculated DART (Days Away, Restricted, or Transferred) rates. Contractors must also report any serious, willful, or repeat OSHA violations from the past three years with supporting explanations and provide copies of completed OSHA 300 and 300a Forms. Additionally, contractors are required to supply their six-digit North American Industrial Classification System (NAICS) Code, identify the individual or department responsible for administering the company's Safety and Health Program, and provide their current Insurance Experience Modification Rate (EMR). This form serves as a screening tool to assess contractor safety performance and compliance history prior to contract award.
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Experience Modification Rate (EMR) Rating
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25026B0040.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020 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):
http://www.osha.gov/pls/publications/publication.html
Pre-Award Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .