EMR 1 page.docx
DOCX document 19 KB Posted
- Solicitation number
- 36C24827Q0004-1
About this file
This is a Pre-Award Contractor Safety and Environmental Record Form that solicits safety and environmental compliance information from potential contractors. The form requires contractors to provide detailed OSHA recordkeeping data for the years 2023 through 2026, including total man hours worked, number of cases involving days away from work or restricted activity, and the Days Away, Restricted, or Transferred (DART) rate calculated using the standard formula of (cases × 200,000) divided by man hours. Contractors must also disclose any serious, willful, or repeat violations issued by OSHA or EPA within the last three years with supporting explanations, and submit copies of OSHA 300 and 300A forms as documentation.
The form additionally requires contractors to identify the individual or department responsible for administering their company's Safety and Health Program and to provide their Insurance Experience Modification Rate (EMR) for the past three years, with a maximum EMR of 1.0 required for eligibility. This pre-award assessment is being used for the solicitation Z1DZ--FY27 NRM (PROJ 516-26-117) issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8 for BB Repair Steam Piping in Manhole Near Building 1 at Bay Pines VAMC in St. Petersburg, Florida. The solicitation is set aside for VetCert-certified Service-Disabled Veteran-Owned Small Businesses (SDVOSB), and interested contractors must be registered in both the Small Business Search database and SAM.gov at the time of quote submission.
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Text version
Attachment Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
| 2026 |
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 or any EPA violations 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. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required):
File details come from the government source that posted it. Updated .