S02_EMR_2 Pages.pdf
PDF 719 KB Posted
- Solicitation number
- 36C26325B0005
About this file
This is a pre-award contractor safety and environmental record evaluation form that outlines requirements for bidders/offerors to submit safety and environmental compliance information. The form includes two main components: safety violation reporting requirements and Experience Modification Rating (EMR) documentation.
Bidders must certify they have no more than three serious violations, one repeat violation, or one willful OSHA/EPA violation in the past three years. They must submit their EMR information from their insurance carrier on official letterhead, with explanations required for rates above 1.0. The form includes a table for reporting man-hours worked, DART rates, and OSHA violations from 2021-2024. Self-insured contractors from specific states (CA, DE, MI, NJ, ND, OH, PA, WA, WY, PR) must obtain EMR ratings from state worker's compensation bureaus. The NAICS code specified is 238210. Contractors must submit OSHA 300 and 300a forms documenting work-related injuries and illnesses. This requirement applies to all subcontracting tiers, with prime contractors responsible for subcontractor compliance.
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Text version
PRE-AW ARD CONTRACTOR SAFETY AND ENVIRONMENT AL RECORD
EVALUATION FORM
Information provided below is current and applicable to Solicitation:
Company Name: ______________________ _ Address: _________________________ _ Telephone: _____________ Fax: __________ _ Email: __________________________ _ Contact: _________________________ _
Utilizing the completed OSHA 300 Forms, please complete the table below:
Category �021 2022 2023 �024
Number of man hours Gobsite 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 (Log of Work-Related Injuries and Illnesses) and 300a Forms (Summary of Work-Related Injuries and Illnesses).
These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
1. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 238210
2. Who administers your company's Safety and Health Program?
3. Company's Insurance Experience Modification Rate (EMR):
FOR OFFICAL USE ONLY 2 of2
File details come from the government source that posted it. Updated .