Attachment II - EMR.pdf
PDF 479 KB Posted
- Attached to
- 539-25-505 Maintain Parking Garage Safety
- Solicitation number
- 36C25026Q0034
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0034. The form requires potential contractors to provide detailed safety and environmental performance metrics for the years 2021-2023, including:
- Number of man-hours (jobsite and office)
- Number of workplace injury cases involving days away from work or restricted activity
- Days away, restricted, or transferred (DART) rate
- Number of serious, willful, or repeat OSHA violations
Contractors must also complete additional information such as their six-digit North American Industrial Classification System (NAICS) Code, the administrator of their company's Safety and Health Program, and their Insurance Experience Modification Rate (EMR). The form requires attachments of OSHA 300 and 300a Forms, which can be accessed through OSHA's publications search page.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25025Q0034
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 .