S06 - EMR Form.pdf
PDF 44 KB Posted
- Attached to
- Y1DZ--556-24-122 B132 Pool and HVAC Replacement
- Solicitation number
- 36C25226B0032_01
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form used to assess contractor safety performance and compliance prior to contract award.
The form requires contractors to provide comprehensive safety and health information across three years (2023, 2024, 2025), including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity, the DART rate (Days Away, Restricted, or Transferred rate) calculated using the standard formula of cases multiplied by 200,000 divided by man hours, and the number of serious, willful, or repeat OSHA violations within the past three years with supporting explanations. Contractors must also submit copies of their OSHA 300 and 300a Forms, accessible through the OSHA publications search page. Additional required information includes the contractor's six-digit North American Industrial Classification System (NAICS) Code for the specific acquisition, identification of the individual or department responsible for administering the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). The form captures basic company identification details including name, address, telephone, fax, email, and contact person. This evaluation tool enables federal agencies to make informed pre-award decisions based on objective safety metrics and historical compliance records.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
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 your 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
| Company Name: |
| Address: |
| Telephone: |
| Fax: |
| Email: |
| Contact: |
| 2023Number of man hours jobsite and office: |
| 2024Number of man hours jobsite and office: |
| 2025Number of man hours jobsite and office: |
| 2023Number of cases involving days away from work restricted activity or both Column H and I of OSHA 300: |
| 2024Number of cases involving days away from work restricted activity or both Column H and I of OSHA 300: |
| 2025Number of cases involving days away from work restricted activity or both Column H and I of OSHA 300: |
| restricted or transferred cases x 200000 of man hours: |
| Number of serious willful or repeat violations from OSHA: |
| acquisition: |
| Who administers your companys Safety and Health Program: |
| Companys Insurance Experience Modification Rate EMR: |
File details come from the government source that posted it. Updated .