S02 - Attachment 05 - EMR Form - 1 page.pdf
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- Solicitation number
- 36C24826R0133
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form used as a solicitation attachment to assess contractor safety and environmental compliance prior to contract award.
The form requires contractors to provide comprehensive safety and health data across three years (2023, 2024, 2025), including total man hours worked at jobsite and office locations, the number of cases involving days away from work or restricted activity, and calculated Days Away, Restricted, or Transferred (DART) rates using the formula of (number of cases × 200,000 / total man hours). Contractors must also disclose the number of serious, willful, or repeat OSHA violations from the preceding three years with attached explanations for any violations, and must submit copies of OSHA 300 and 300a Forms accessible through the OSHA publications search page. Additionally, the form requires collection of basic company information including name, address, telephone, fax, email, and primary contact, along with the contractor's six-digit North American Industrial Classification System (NAICS) Code, identification of the individual or department administering the company's Safety and Health Program, and the company's current Insurance Experience Modification Rate (EMR).
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Text version
Solicitation Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award 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 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 your 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 http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .