Attachment II - EMR.pdf
PDF 459 KB Posted
- Solicitation number
- 36C25026Q0495
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form applicable to federal solicitation 36C25026Q0495. The form is a template designed to collect and evaluate a contractor's safety and health performance prior to contract award.
The form requires contractors to provide company information (name, address, contact details) and complete a three-year safety record assessment covering 2022, 2023, and 2024. Contractors must report man hours worked (jobsite and office combined), the number of cases involving days away from work or restricted activity using OSHA 300 form data, the calculated DART rate (Days Away, Restricted, or Transferred rate), and the number of serious, willful, or repeat OSHA violations incurred within the preceding three years with explanatory documentation. Additional required information includes the six-digit NAICS code for the acquisition, identification of the individual administering the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). Contractors must attach copies of their OSHA 300 and 300a forms, which are available through the OSHA publications search page. This template serves as the evaluation mechanism for assessing contractor safety compliance and risk prior to award of the federal contract.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25026Q0495
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2022 2023 2024
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.
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 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):
File details come from the government source that posted it. Updated .