36C25622R0067 EXHIBIT D R1.docx
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- Solicitation number
- 667-22-4-1404-0033
About this file
This document contains a contractor evaluation form and details of a federal contract opportunity for repairing a water distribution system at a Veterans Affairs medical center. The contractor evaluation form requests safety-related information including OSHA recordable incident rates, violations, and insurance experience modification rates. Offerors must provide documentation including OSHA forms and a letter from their insurer regarding their experience modification rate.
The related federal contract opportunity is a 100% SDVOSB set-aside solicitation to upgrade the water distribution system at the Shreveport, LA VA Medical Center. Offerors must be registered in the System for Award Management and Vendor Information Pages and respond in accordance with the solicitation package. The requirement is being conducted by VA Networks 16 under NAICS code 236220 with a size standard of $39.5M.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-119 Repair Water Distribution System – Main Hospital 36C25622R0067
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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