Attachment II - EMR.pdf

This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form applicable to Solicitation #36C25026Q0508. The form is a template designed to collect safety and occupational health data from contractors bidding on a federal contract opportunity.

The form requires contractors to provide company identification information including name, address, telephone, fax, email, and primary contact. Contractors must complete a three-year safety history table (2022-2024) using OSHA 300 Forms data, documenting total man hours worked, number of cases involving days away from work or restricted activity (Column H and I of OSHA 300), the Days Away, Restricted, or Transferred (DART) Rate calculated using the formula (number of cases × 200,000 ÷ man hours), and the number of serious, willful, or repeat OSHA violations within the last three years with required explanations. Contractors must attach copies of completed OSHA 300 and 300a Forms, available through the OSHA publications search page. Additional required information includes the six-digit North American Industrial Classification System (NAICS) Code for the acquisition, identification of the individual or department administering the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). This evaluation form serves as a pre-award assessment tool to evaluate contractor safety performance and environmental compliance records prior to contract award.