Attachment IV - Contractor EMR Certification Form 610A4-25-226.pdf
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- Attached to
- Z1DA--Update Patient Wifi 610A4-25-226
- Solicitation number
- 36C25026B0012_1
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Project 610A4-25-226. The form serves as a template for collecting and evaluating a contractor's safety and environmental performance history prior to contract award.
The form requires contractors to provide company identification information and complete a four-year safety record summary covering 2021 through 2024. Contractors must report total man hours worked at jobsite and office locations, the number of cases involving days away from work or restricted activity, the calculated Days Away, Restricted, or Transferred (DART) rate, and the number of serious, willful, or repeat OSHA violations incurred within the preceding three years with supporting explanations. Additionally, contractors must submit copies of their OSHA 300 and 300a Forms, provide their six-digit North American Industrial Classification System (NAICS) code (specified as 238210 for this acquisition), identify the individual or department administering the company's Safety and Health Program, and disclose their Insurance Experience Modification Rate (EMR). All information provided must be current and applicable to the specified project.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 610A4-25-226
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 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: 238210
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate
(EMR):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .