ATTACHMENT 8 - EMR.pdf
PDF 127 KB Posted
- Solicitation number
- 36C24826R0028
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EMR Form Summary
This is a Pre-Award Contractor Evaluation Form that bidders/offerors must complete and submit with their proposals. The form requires contractors to provide company identification information including name, address, telephone, fax, email, and primary contact name. The form functions as a template for collecting safety and health performance data used to evaluate contractor qualifications prior to award.
The form requires submission of four key evaluation categories: (1) OSHA 300 Forms data for 2022 through 2025, including man hours worked, cases involving days away from work or restricted activity, and calculated DART rates; (2) the contractor's six-digit North American Industrial Classification System (NAICS) code; (3) identification of the individual who administers the company's Safety and Health Program; and (4) the company's Insurance Experience Modification Rate (EMR) for the past three years. Contractors must also provide documentation of any serious, willful, or repeat OSHA violations from the past three years with explanations. Disqualifying criteria include four or more serious violations, one repeat violation, one willful violation, or an EMR greater than 1.0. Contractors are required to attach copies of their OSHA 300 and 300a Forms, which are available through the OSHA publications search page.
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Text version
EMR FORM
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 2022 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. (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): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .