36C25622R0062 EXHIBIT D.docx
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- Solicitation number
- 36C25622R0062
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This document contains a contractor evaluation form for a construction safety company bidding on Project No. 667-19-101 Tuckpoint Building 1, Main Hospital with the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form requests information on the company's OSHA 300 and 300a forms from 2019 to 2021 including man hours, days away from work cases, restricted activity cases, DART rate, and any serious, willful, or repeat OSHA violations. It also requests the name of the company's safety program administrator and current insurance EMR rate on insurer letterhead including an explanation if the EMR is over 1.0.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-19-101 Tuckpoint BLDG 1, Main Hospital 36C25622R0062 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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