ATTACHMENT 2 - EMR.pdf
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- Solicitation number
- 36C24826R0090
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EMR Form for Bidder/Offeror - Pre-Award Contractor Evaluation
This is a Pre-Award Contractor Evaluation Form template that bidders/offerors must complete and submit with their proposals to demonstrate safety and health program performance. The form requests company identification information including name, address, telephone, fax, email, and primary contact.
The form requires submission of OSHA safety data for the past three years (2023-2025), including total man-hours worked at job sites and offices, the number of cases involving days away from work or restricted activity (DART cases), calculated DART rates, and documentation of serious, willful, or repeat OSHA violations with explanatory attachments. Bidders must also provide their six-digit NAICS code, identify the individual administering their Safety and Health Program, and report their Insurance Experience Modification Rate (EMR) for the past three years. The form specifies disqualifying criteria: four or more serious violations, one or more repeat violations, one or more willful violations, or an EMR exceeding 1.0. Bidders are required to attach copies of OSHA 300 and 300a Forms, which can be accessed through the official OSHA publications website.
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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 2023 2024 2025 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 .