36C25621R0136 EXHIBIT D.docx
DOCX document 28 KB Posted
- Attached to
- Z1DA--520-19-117 Repair Water Supply
- Solicitation number
- 36C25621R0136
About this file
This document contains an evaluation form and instructions for a federal construction contract opportunity to repair water supply systems at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi. The evaluation form requests safety information such as OSHA recordable incident rates for the past three years, documentation of serious violations, insurance experience modification rates, and administration of safety programs. The related federal contract opportunity is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses to provide all labor, materials, equipment, and supervision for the water supply repair project with a performance period of 365 calendar days from notice to proceed. The solicitation number is 36C25621R0136 and the procurement will follow FAR Part 15 procedures with proposals due around September 6, 2021 and contract award anticipated within 30 days thereafter. The construction cost range is $2-5 million and the NAICS code is 238220.
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Other files
| File | Type | Posted |
|---|---|---|
| Pre-Award RFI Register 520-19-117 31 Aug 21.docx | DOCX document | |
| 36C25621R0136 0004.docx | DOCX document | |
| 36C25621R0136 0003.docx | DOCX document | |
| VHA Directive 1193 COVID 2019 Vaccination August 13 2021.pdf | ||
| 36C25621R0136 0002.docx | DOCX document | |
| S04 Site Visit Sign-In Sheet - Proj 520-19-117.pdf | ||
| 36C25621R0136 0001.docx | DOCX document | |
| 36C25621R0136 EXHIBIT E.docx | DOCX document | |
| 36C25621R0136 Drawings 1-4.pdf | ||
| 36C25621R0136 WD MS20210050 04022021 Mod 2.pdf | ||
| 36C25621R0136 EXHIBIT A.docx | DOCX document | |
| 36C25621R0136 EXHIBIT C.docx | DOCX document | |
| 36C25621R0136 Drawings 5-10.pdf | ||
| 36C25621R0136 RFP.docx | DOCX document | |
| 36C25621R0136 Specifications 01.pdf | ||
| 36C25621R0136 J_A.pdf | ||
| 36C25621R0136 EXHIBIT F.docx | DOCX document | |
| 36C25621R0136 EXHIBIT B.docx | DOCX document | |
| 36C25621R0136 Drawings 11-18.pdf | ||
| 36C25621R0136 SOW .docx | DOCX document | |
| 36C25621R0136 ICRA.pdf |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-19-117 Repair Water Supply 36C25621R0136
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.
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