S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
PDF 93 KB Posted
- Attached to
- 5680--608-24-115 Interior Stairwell Resurfacing
- Solicitation number
- 36C24124B0049
About this file
This document is a Pre-Award Contractor Evaluation Form that must be completed and submitted with a proposal in response to a federal contract opportunity. The form requires the contractor to provide information about their OSHA safety record, including number of man-hours, OSHA recordable incidents, DART rate, and OSHA violations. It also asks for the contractor's NAICS code, who administers their safety program, and their Insurance Experience Modification Rate (EMR) for the past 3 years. This information is likely used to assess the contractor's safety performance and qualifications prior to contract award.
The related federal contract opportunity is for Interior Stairwell Resurfacing at the Manchester VAMC in New Hampshire, solicitation number 36C24124B0049. This is an Invitation for Bid (IFB) issued by the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 1.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24124B0049 0006.docx | DOCX document | |
| 36C24124B0049 0005.docx | DOCX document | |
| 36C24124B0049 0004.docx | DOCX document | |
| 608-24-115 Bid Site Walk Check-in.pdf | ||
| 36C24124B0049 0003.docx | DOCX document | |
| 36C24124B0049 0002.docx | DOCX document | |
| 36C24124B0049 0001.docx | DOCX document | |
| 608-24-115 Stairwell Wall Repair SOW.pdf | ||
| 36C24124B0049_1.docx | DOCX document |
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Text version
PRE-AWARD CONTRACTOR EVALUATION FORM
COMPLETE & SUBMIT WITH PROPOSAL
(FROM CFM WEBSITE)
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022 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. (Four serious, one repeat, or one willful disqualifies the contractor.)
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) for the past 3 years: _____________
File details come from the government source that posted it. Updated .