36C25621R0109 EXHIBIT D.docx
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- Attached to
- Z1DZ-- Proj No 520-22-113 Access Control &Security Systems Upgrade Federal contract opportunity
- Solicitation number
- 36C25621R0109
About this file
This document contains an exhibit for evaluating contractor safety pertaining to a solicitation for access control and security system upgrades. The solicitation requests information on offerors' OSHA 300 forms from 2018 to 2020 including man hours, days away from work cases, and DART rates. It also requests copies of OSHA forms, identification of the safety program administrator, and the company's current EMR rate from its insurance carrier.
The related federal contract opportunity is a 100% SDVOSB set-aside issued through the Department of Veterans Affairs for project number 520-22-113 involving access control and security system upgrades at the Gulf Coast Veterans Health Care System. The solicitation number is 36C25621R0109 with an estimated value between $1,000,000 and $2,000,000. The performance period is 180 days from notice to proceed with proposals due around September 6, 2021 and award approximately 30 days later. The NAICS code is 238210 and size standard is $16.5M. Offerors must meet SDVOSB and SAM registration requirements.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-113 Access Control & Security System Upgrades 36C25621R0109
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 |
| 2018 |
| 2019 |
| 2020 |
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 .