EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
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- Attached to
- RFP***Z2DA--NRM - 502-19-103 Remove and replace air handling units Bldg. 7 Federal contract opportunity
- Solicitation number
- 36C25620R0143
About this file
This document contains an evaluation form for contractor safety and a related federal contract opportunity notice. The evaluation form requests safety-related information from offerors such as man hours, OSHA recordable incidents, rates, violations, and insurance experience modification rates. It will be used to evaluate offerors for a contract to replace air handling units at a Veterans Affairs medical center facility located in Pineville, Louisiana. The pre-solicitation notice identifies a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses to issue a request for proposal around May 8th, 2020 for replacing the HVAC system. Proposals will be due approximately June 8th, 2020 with an anticipated award date around 30 days later. The contract period of performance will be 365 days after notice to proceed. The construction cost range is between $5-10 million.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 502-19-103 Replace BLDG 7 AHU’s 36C25620R0143
Exhibit D Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2017 |
| 2018 |
| 2019 |
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 explanations 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. | Who administers your company’s Safety and Health Program? |
| 3. | Company’s current Insurance Experience Modification Rate (EMR): |
The above EMR rate must be obtained from offeror’s insurance carrier and furnished on insurance carrier’s letterhead. If EMR is greater than 1.0, attach a written explanation of the EMR from insurance carrier on insurance carrier’s letterhead describing the reasons for the EMR and the anticipated date the EMR may be reduced to 1.0 or below.
File details come from the government source that posted it. Updated .