Attachment II - EMR.pdf
PDF 459 KB Posted
- Solicitation number
- 36C25026Q0519
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form applicable to federal solicitation 36C25026Q0519. The form serves as a template for contractors to submit comprehensive safety and health program documentation during the pre-award evaluation phase of the federal contracting process.
The form requires contractors to provide company contact information and detailed occupational safety and health data covering a three-year period (2022-2024). Specifically, contractors must report total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity using OSHA 300 Form columns H and I, calculated DART rates (Days Away, Restricted, or Transferred rates), and the number of serious, willful, or repeat OSHA violations incurred within the last three years, with required explanations for any violations. Additionally, contractors must submit copies of completed OSHA 300 and 300a Forms, provide their six-digit North American Industrial Classification System (NAICS) code applicable to the acquisition, identify the individual or department administering the company's Safety and Health Program, and disclose their company's Insurance Experience Modification Rate (EMR). This evaluation form enables the federal government to assess contractor safety performance and environmental compliance records prior to contract award.
View the file
Other files
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25026Q0519
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 .