Attachment II - EMR.pdf
PDF 479 KB Posted
- Attached to
- Medium Voltage Switchgear Testing
- Solicitation number
- 36C25025Q0925
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation # 36C25025Q0925. The form requires potential contractors to provide detailed safety and environmental performance information, including OSHA-related metrics for the years 2021-2023. Specifically, contractors must document their total man-hours, workplace injury/restriction cases, Days Away, Restricted, or Transferred (DART) rate, and any serious OSHA violations.
The form requests additional documentation including OSHA 300 and 300a Forms, the company's six-digit North American Industrial Classification System (NAICS) Code, details about who administers the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). Contractors are expected to complete the table with their safety performance data and attach required supporting documentation to demonstrate their safety record and compliance with workplace safety standards.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25025Q0925
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 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.
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 .