Attachment C - Contractor EMR Certification Form 2022.docx

Pre-Award Contractor Experience Modification Rate (EMR) Form

Information regarding your EMR is being sought in conjunction with your quote applicable to Solicitation 36C24623Q0462 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”

Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:

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.

2. Please attach copies of the following documents: a)2021 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b)Letter from insurance carrier stating current EMR rate.

3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________

4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.

5. Your company’s Insurance Experience Modification Rate (EMR): ______