EMR 1 page.pdf
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- Solicitation number
- 36C24826Q0188
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Form, designed to collect comprehensive safety and environmental performance data from potential contractors. The form requires detailed information across three years (2022-2024), including total man-hours worked, workplace injury/restriction cases, Days Away, Restricted, or Transferred (DART) rates, and any serious, willful, or repeat OSHA or EPA violations. Contractors must also specify who administers their Safety and Health Program and provide their Insurance Experience Modification Rate (EMR), with a requirement that the EMR be 1 or less. Additionally, the form mandates that companies attach copies of their OSHA 300 and 300a Forms as supporting documentation, which can be accessed through the OSHA publications search page.
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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 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 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): _____________ http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .