Attachment XIV - EMR Form.pdf
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- Attached to
- Z2DA--Remediate Temperature Controls 539-21-108 Federal contract opportunity
- Solicitation number
- 36C25026B0002
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation No. 36C25026B0002. The form requires contractors to provide detailed safety performance information, including OSHA recordkeeping data for 2022-2024. Specifically, contractors must report:
- Number of man hours (jobsite and office)
- Number of cases involving days away from work or restricted activity
- Days away, restricted, or transferred rate (DART Rate)
- Number of serious, willful, or repeat OSHA violations within the last 3 years
Additional required information includes the company's six-digit NAICS Code (238220), the administrator of the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). Contractors are also instructed to attach copies of their OSHA 300 and 300a Forms as supporting documentation.
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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. 36C25026B0002.
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: 238220
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 .