Attachment E_Contractor Evaluation Form.pdf
PDF 101 KB Posted
- Attached to
- Y1DZ--598-19-127 Bldg 104 Renovations
- Solicitation number
- 598-19-127
About this file
This document is an EMR (Experience Modification Rate) Form for Pre-Award Contractor Evaluation. The form requires bidders/offerors to provide detailed safety and occupational health information, including:
- Comprehensive safety metrics for the years 2020-2023, such as total man hours, workplace injury/restriction cases, Days Away, Restricted, or Transferred (DART) rate, and OSHA violations. Contractors are disqualified if they have four serious violations, one repeat violation, or one willful violation. Bidders must attach their OSHA 300 and 300a Forms as supporting documentation. Additionally, the form requests the company's six-digit NAICS code, details about who administers their Safety and Health Program, and their Insurance Experience Modification Rate (EMR), with an EMR greater than 1.0 resulting in disqualification.
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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 2020 2021 2022 2023 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 .