S02 - Attachment 6 - Contractor Safety and Environmental Record Evaluation Form.pdf
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- Attached to
- Z1DA--596A4-18-102 - Replacement elevators Federal contract opportunity
- Solicitation number
- 36C24923R0021
About this file
This document contains a pre-solicitation notice and related pre-award evaluation form for an upcoming federal contract opportunity. The pre-solicitation notice seeks proposals for construction services to upgrade five elevators at the Lexington Veterans Affairs Medical Center in Lexington, Kentucky. The construction budget for the project is between $1 million and $2 million. The NAICS code for the work is 236220 for commercial and institutional building construction. The opportunity is set aside exclusively for verified service-disabled veteran-owned small businesses. The pre-award evaluation form requests safety and environmental records information from prospective contractors, including OSHA forms, insurance rates, and safety program details, to be evaluated prior to award. The solicitation is expected to be issued on or around November 30, 2022.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923R0021
Company Name: ____________________________
Address: ____________________________
Telephone: ____________________________
Email: ____________________________
Contact: ____________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2019 2020 2021
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 six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220 – Commercial and Institutional Building Construction
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
File details come from the government source that posted it. Updated .