Attachment VIII - EMR Form.pdf
PDF 159 KB Posted
- Attached to
- Z2DA--Renovate MICU/SICU 539-20-104
- Solicitation number
- 36C25026B0001
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation No. 36C25026B0001. It requires potential contractors to provide detailed safety and environmental performance information, including OSHA 300 form data for 2022-2024. Specifically, contractors must report their total man-hours, number of workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and any serious, willful, or repeat OSHA violations from the past three years.
The form also requests additional company information, including the six-digit NAICS Code (236220), details about who administers the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). Contractors are instructed to attach copies of their OSHA 300 and 300a Forms, which can be accessed through the OSHA publications search page. The form is designed to evaluate a contractor's safety record and environmental performance as part of the pre-award assessment process.
View the file
Other files
Show all 25
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation No. 36C25026B0001.
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 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: 236220
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 .