36C25622R0017 Exhibit A Contractor Evaluation Form - Construction Safety.docx
DOCX document 29 KB Posted
- Attached to
- Project #667-23-102 Expand Dialysis (DB) Federal contract opportunity
- Solicitation number
- 36C25623R0017
About this file
This document contains a contractor evaluation form for construction safety related to Federal Solicitation Number 36C25623R0017 for Project #667-23-102 to expand dialysis facilities at a Veterans Affairs medical center. The form requests safety-related information from offerors such as man-hours and OSHA incident rates for the previous three years, explanations for any OSHA violations, copies of OSHA forms, identification of the company's safety administrator, and the company's current insurance experience modification rate along with an explanation if it is above 1.0. Offerors are also advised that submitted information is designated as source selection sensitive.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25623R0017 0001.pdf | ||
| 36C25623R0017 0002.pdf | ||
| P09 Attachment B - 4E Existing Layout.pdf | ||
| WD LA20230031 dated 01-06-2023.txt | TXT text file | |
| 4 East Dialysis Center Expansion ICRA FINAL.docx | DOCX document | |
| P09 SOW Final.pdf | ||
| 36C25623R0017 FINAL 1-9-23.docx | DOCX document | |
| P09 Attachment A - 4E Dialysis Floor Plan.pdf |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-23-102 Expand Dialysis (DB) 36C25623R0017
Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
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 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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