Attachment IV - EMR.pdf
PDF 135 KB Posted
- Attached to
- Z1DA--Remodel Building 1, Marion 610-21-101
- Solicitation number
- 36C25026B0007
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25026B0007. The form requires potential contractors to provide detailed safety and environmental performance metrics across three years (2022-2024), including:
Contractors must complete a table documenting their man-hours, workplace injury/absence cases, Days Away, Restricted, or Transferred (DART) rate, and OSHA violations. Additionally, they are required to attach OSHA 300 and 300a forms, provide their six-digit NAICS code, identify who administers their Safety and Health Program, and disclose their Insurance Experience Modification Rate (EMR). The form serves as a comprehensive safety evaluation mechanism to assess a contractor's workplace safety record and environmental compliance before potential contract award.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25026B0007.
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 an 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):
http://www.osha.gov/pls/publications/publication.html
Pre-Award Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .