Attachment XII - EMR Form.pdf
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- Solicitation number
- 36C25026Q0789
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C25026Q0789. The form is a template designed to collect safety and health program information from prospective contractors prior to contract award.
The form requires contractors to provide company identification information (name, address, telephone, fax, email, and contact person) and complete a three-year safety performance history table covering 2023, 2024, and 2025. Contractors must report total man hours worked at jobsite and office locations, the number of cases involving days away from work or restricted activity per OSHA 300 Forms, the calculated DART (Days Away, Restricted, or Transferred) rate, and the number of serious, willful, or repeat OSHA violations incurred within the last three years with explanations for any violations. Contractors must also attach copies of their OSHA 300 and 300a Forms. Additionally, the form requires submission of the six-digit NAICS code (238210 is pre-filled), identification of the individual administering the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). This evaluation form serves as a pre-award assessment tool to evaluate contractor safety performance and compliance history before contract execution.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25026Q0789:
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2023 2024 2025
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: __________ 238210________________________
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 .