EMR 1 page.pdf
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- Solicitation number
- 36C24826Q0450
About this file
This is a Pre-Award Contractor Safety and Environmental Record Form used to evaluate a contractor's safety and environmental compliance history prior to contract award.
The form requires contractors to provide company identification information (name, address, telephone, fax, email, and contact person) and complete a three-year safety record data table covering 2023, 2024, and 2025. Specifically, contractors must report total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity using OSHA 300 form columns H and I, and the calculated Days Away, Restricted, or Transferred (DART) rate using the formula of cases multiplied by 200,000 divided by man hours. Additionally, contractors must disclose the number of serious, willful, repeat violations from OSHA or EPA violations within the past three years, with explanations attached for any violations. Contractors must also identify the individual or department administering the company's Safety and Health Program and provide the company's Insurance Experience Modification Rate (EMR) for the past three years, with a mandatory requirement that the EMR not exceed 1.0. Supporting documentation includes copies of OSHA 300 and 300a Forms, which are available through the OSHA publications search page.
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| WD-FL20260211-DATED 05-18-2026.pdf | ||
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| 36C24826Q0450 0002.docx | DOCX document | |
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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
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 .