Contractor EMR Certification Form.pdf
PDF 88 KB Posted
- Attached to
- Construction - Replace Roof (539-21-113)
- Solicitation number
- 36C25022B0029_1
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Text version
Contractor Safety and Environmental Record Evaluation Form
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2019 2020 2021
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 .