36C25622R0030 EXHIBIT D-Contractor Evaluation Form Construction Safety .docx
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- Attached to
- Z2FB--Biloxi MATOC-Seed Project Project #520-22-122 FCA Corrections BLDG 17 - 36C25622R0030
- Solicitation number
- 520-22-122
About this file
This document contains a contractor evaluation form for construction safety related to a federal construction contract opportunity. The form requests safety-related information from contractors including total man hours, OSHA recordable incidents, days away from work rates, and serious violations over the past three years. Contractors must provide supporting documentation including OSHA 300 and 300a forms and an explanation if their experience modification rate is over 1.0.
The related federal contract opportunity is for a MATOC seed project at the Biloxi VA Medical Center under Solicitation 520-22-122. The contracting agency is the Department of Veterans Affairs Veterans Health Administration VISN 16. Contractors must demonstrate a safety history and program that meet the criteria in the evaluation form to be considered for this construction contract.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-122 FCA Corrections BLDG 17-MATOC Seed Project 36C25622R0030
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 |
| 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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