Attachment 06 - Safety or Environmental Violations and Experience Modification Rate EMR Form 1 page.pdf
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- Solicitation number
- 36C24822R0072
About this file
This document contains a pre-award contractor safety evaluation form and requests information on a company's safety record and insurance rates. The form seeks details on a contractor's OSHA 300 forms from 2019 to 2021 such as number of man hours, days away from work cases, and serious violations. It requests the company's NAICS code and administrator of its safety program. Contractors must also disclose their experience modification rate, which is an insurance industry rating of a company's losses relative to its industry peers.
The related federal contract opportunity is a solicitation from the Department of Veterans Affairs for site preparation and design-build services to acquire land for the San Juan Fisher House in Puerto Rico. Offerors would be required to provide information on their safety records and insurance rates using the attached evaluation form.
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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 2019 2020 2021
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
File details come from the government source that posted it. Updated .