36C25622R0065 EXHIBIT D R1.docx
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- Attached to
- Z1DA--667-18-121 Upgrade & Replace Surgery HVAC System & Roofing Federal contract opportunity
- Solicitation number
- 36C25622R0065
About this file
This document contains a contractor evaluation form for a construction project. The form requests safety and health information from offerors, including OSHA 300 and 300a forms from the past three years detailing man-hours worked, days away from work cases, and serious violations. It also asks for the identity of the offeror's safety program administrator and current insurance experience modification rate, requiring an explanation from the carrier if the rate exceeds 1.0.
The related federal contract opportunity is a solicitation notice for Project 667-18-121 to upgrade and replace the surgery HVAC system and roofing at the Overton Brooks VA Medical Center in Shreveport, Louisiana. The solicitation is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. Offerors would be evaluated based on the safety information requested in the contractor evaluation form.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-121 Upgrade Surgery HVAC & Roofing 36C25622R0065 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.
File details come from the government source that posted it. Updated .