ATTACHMENT 9 - EMR.pdf
PDF 209 KB Posted
- Attached to
- J061--PROJECT 675-25-804, Bid-Build (BB) Install Water Tower Projector System at Lake Nona
- Solicitation number
- 36C24826R0107
About this file
This is a Pre-Award Contractor Evaluation Form (EMR Form) that bidders and 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. Section 1 requests safety and health data from OSHA 300 Forms for the years 2022 through 2025, specifically requiring the number of man hours (jobsite and office), number of cases involving days away from work or restricted activity, calculated DART rates (days away, restricted, or transferred rate), and the number of serious, willful, or repeat OSHA violations within the last three years with attached explanations. Contractors must also submit copies of their OSHA 300 and 300a Forms. Section 2 requires the contractor's six-digit North American Industrial Classification System (NAICS) Code for the acquisition. Section 3 asks who administers the company's Safety and Health Program. Section 4 requires the company's Insurance Experience Modification Rate (EMR) for the past three years. The form establishes disqualification thresholds: contractors with four serious violations, one repeat violation, or one willful violation are automatically disqualified, as are contractors with an EMR greater than 1.0. This evaluation form is designed to assess contractor safety performance and risk before contract award.
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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 VHAWPBZorziM Cross-Out
File details come from the government source that posted it. Updated .