Attachment VIII - EMR Form.pdf
PDF 159 KB Posted
- Attached to
- Z2DA--Renovate MICU/SICU 539-20-104
- Solicitation number
- 36C25026B0001_1
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation No. 36C25026B0001. The form requires potential contractors to provide detailed safety performance information using OSHA 300 Forms, including data on man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations for the years 2022-2024. Contractors must also include their six-digit North American Industrial Classification System (NAICS) Code (236220 for this acquisition), identify who administers their Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR).
The form instructs contractors to attach copies of OSHA 300 and 300a Forms, which can be accessed through the OSHA publications search page. The evaluation appears to be part of a pre-award assessment to review a potential contractor's safety record and environmental performance, likely for a construction or industrial services contract. The form is designed to help the contracting agency assess the safety and risk management capabilities of potential bidders before awarding the contract.
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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 .