36C25618R0574-005.docx
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- CLC MODIFICATIONS Federal contract opportunity
- Solicitation number
- 36C25618R0574
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36C25618R0574 EXHIBIT A CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
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FOR OFFICIAL USE ONLY
VA256-18-R-0574
Exhibit A Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2015 |
| 2016 |
| 2017 |
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 may disqualify 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. Who administers your company’s Safety and Health Program?
3. Company’s current Insurance Experience Modification Rate (EMR) (an EMR of greater than 1.0 may disqualify the contractor):
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