Contractor EMR Certification Form.pdf
PDF 141 KB Posted
- Solicitation number
- 36C24926R0021
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24926R0021. The form is a template used to collect and assess contractor safety performance and compliance data prior to contract award.
Contractors must provide comprehensive safety information covering three years (2023, 2024, and 2025), including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity, and calculated DART (Days Away, Restricted, or Transferred) rates using the formula of cases multiplied by 200,000 divided by man hours. Additionally, contractors must report the number of serious, willful, or repeat OSHA violations from the preceding three years and provide explanations for any violations. Supporting documentation required includes copies of OSHA 300 and 300a Forms, accessible through the OSHA publications search page. The form also requests the six-digit NAICS Code applicable to the acquisition, identification of the individual or department administering the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). Basic company contact information including name, address, telephone, fax, email, and primary contact must be provided at the top of the form.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24926R0021
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2023 2024 2025
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:
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 .