Contractor Pre-Award OSHA Evaluation Form.pdf
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- Attached to
- Z1DA--LOCAL minimum guarantee base Construction MATOC| Lebanon-Altoona Construction MATOC (VA-26-00000908)
- Solicitation number
- 36C24425R0084
About this file
The document is a Pre-Award Contractor Evaluation Form designed to assess a contractor's safety performance and qualifications. The form requires detailed safety information including historical data on man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations for the years 2021-2024. Key evaluation criteria include: attaching OSHA 300 and 300a Forms, describing the company's safety philosophy, providing industry classification codes, identifying the administrator of the company's Safety and Health Program, and reporting the Insurance Experience Modification Rate (EMR). Contractors can be disqualified for having four serious violations, one repeat violation, one willful violation, or an EMR greater than 1.0.
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Pre-Award Contractor Evaluation Form
Pre-Award Contractor Evaluation Form Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: __________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021
Current year - 4
Current year - 3
Current year - 2
Current year - 1
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.
1. Describe the safety philosophy of your company:
2. Provide your four-digit Standard Industrial Classification (SIC) or six-digit North American Industrial Classification System (NAICS) Code: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): ______________ http://www.osha.gov/pls/publications/publication.html
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