Attachment 05 - Safety or Environment.pdf
PDF 233 KB Posted
- Solicitation number
- 36C24826R0124
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that serves as a solicitation attachment for federal contract opportunities. The form requires contractors to provide comprehensive safety and environmental compliance documentation across three years (2023, 2025, and 2025) using OSHA 300 Forms as the primary source.
The form requests specific safety metrics including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity, and the calculated Days Away, Restricted, or Transferred (DART) Rate using the standard formula of cases multiplied by 200,000 divided by man hours. Additionally, contractors must disclose any serious, willful, or repeat violations issued by OSHA within the last three years and provide written explanations for each violation. Supporting documentation requirements include copies of completed OSHA 300 and 300a Forms, accessible through the OSHA publications search page. Beyond injury and violation data, the form requires contractors to supply their six-digit North American Industrial Classification System (NAICS) Code, identify the individual or department administering the company's Safety and Health Program, and provide the company's Insurance Experience Modification Rate (EMR). The form includes standard contractor identification fields for company name, address, telephone, fax, email, and primary contact information.
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Solicitation Attachment
Safety or Environmental Violations and Experience Modification Rate
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): _____________
VHATAMGammA Cross-Out
File details come from the government source that posted it. Updated .