36C25622R0073 EXHIBIT D.docx
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- Attached to
- Z1DZ--Project# 502-20-113 Building 9 - 3rd Floor Anti-Ligature Renovations - Construction
- Solicitation number
- 36C25622R0073
About this file
This document contains an exhibit for evaluating contractor safety on a construction project. It requests the contractor's OSHA 300 and 300a forms from 2019 to 2021, detailing man hours, injury cases, days away from work rates, and serious violations. It also asks who administers the company's safety program and the current insurance experience modification rate, requiring an explanation if over 1.0.
The related federal contract opportunity is a solicitation for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. It involves project number 502-20-113 for renovations to building 9's third floor to add anti-ligature features at a medical center, with the RFP attached. Contractors are to submit safety documentation and insurance rates using the exhibit to be evaluated for the construction work.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 502-20-113 BLDG 9 – 3rd Floor Anti-Ligature Renovations 36C25622R0073 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 .