Attachment 05 - Safety or Environmental Violations and Experience Modification Rate EMR Form - 1.pdf

184 KB Posted

Attached to
Renovate Interventional Radiology Suites (Construction Services)
Solicitation number
36C24826R0038
Issued by

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This document is a Solicitation Attachment for a Pre-Award Contractor Safety and Environmental Record Evaluation Form. The form requires detailed safety and environmental information from potential contractors, including three years of data (2022-2024) on man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Contractors must provide their NAICS code, identify who administers their Safety and Health Program, and disclose their Insurance Experience Modification Rate (EMR). Additionally, they are instructed to attach copies of their OSHA 300 and 300a Forms, which can be accessed through the OSHA publications search page, and provide explanations for any serious, willful, or repeat violations within the past three years.

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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 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.

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 .