Updated Attachment E Contractor Evaluation Form.pdf
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- Attached to
- Y1DZ--598-19-127 Bldg 104 Renovations
- Solicitation number
- 598-19-127
About this file
This document is an EMR (Experience Modification Rate) Form for Pre-Award Contractor Evaluation, designed for bidders/offerors to complete and submit with their proposal. The form requires detailed safety and health information, including OSHA reporting metrics for the past four years (2020-2023). Contractors must provide data on man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Key disqualifying criteria include having an EMR greater than 1.0 or more than four serious violations, one repeat violation, or one willful violation. Bidders are required to attach OSHA 300 and 300a forms, provide their six-digit NAICS code, identify who administers their safety and health program, and document their company's insurance experience modification rate.
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Text version
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 2020 2021 2022 2023 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 .