A0002_Attachment A - EMR Form.pdf
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- Solicitation number
- 36C25626R0006
About this file
This is a Pre-Award Contractor Evaluation Form (EMR Form) that bidders/offerors must complete and submit with their proposals for federal contract 36C25626R0006. The form is a template requiring contractors to provide company contact information and safety performance data across four years (2021-2024).
The form requires submission of occupational safety and health metrics including total man hours worked at jobsite and office locations, number of cases involving days away from work or restricted activity, and calculation of the Days Away, Restricted, or Transferred (DART) Rate using the formula of cases multiplied by 200,000 divided by man hours. Contractors must also disclose the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations; four serious violations, one repeat violation, or one willful violation will result in disqualification. Additional required information includes the contractor's six-digit NAICS code, identification of the individual administering the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR) for the past three years. An EMR greater than 1.0 disqualifies the contractor. Bidders must attach copies of OSHA 300 and 300a Forms, which are accessible through the OSHA publications search page.
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Text version
36C25626R0006
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023 2024 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. (Four serious, one repeat, or one willful disqualifies the contractor.)
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) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .