ATTACHMENT 2 - EMR.pdf
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- Solicitation number
- 36C24825R0079
About this file
This document is an EMR (Experience Modification Rate) Form for Bidders/Offerors to complete and submit with a proposal. The form requires detailed safety and health information from potential contractors, including three years of workplace safety data from OSHA 300 Forms. Key evaluation criteria include: number of man hours, cases involving days away from work, Days Away, Restricted, or Transferred (DART) rate, and the number of serious, willful, or repeat OSHA violations. Contractors are disqualified if they have four serious violations, one repeat violation, or one willful violation, or if their Insurance Experience Modification Rate (EMR) is greater than 1.0. The form also requests the company's NAICS Code, contact information for the Safety and Health Program administrator, and requires attachments of OSHA 300 and 300a Forms.
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EMR 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
Number of man hours (job site and office)
The number of cases involving days away from work, restricted activity, or both (Columns 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).
The number of serious, willful, or repeat violations from OSHA within the last 3 years.
Please attach an 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): _____________
File details come from the government source that posted it. Updated .