36C25622R0075 Exhibit A Contractor Evaluation Form - Construction Safety.docx
DOCX document 31 KB Posted
- Solicitation number
- 629-22-135
About this file
This document contains a contractor evaluation form for a construction safety evaluation related to a federal contract opportunity for site preparation work for a dual energy CT project. The form requests safety-related information from prospective contractors such as man-hours and OSHA recordable incident rates for the past three years, explanations for any serious OSHA violations, copies of OSHA forms 300 and 300a, identification of the company's safety program administrator, and the company's current insurance experience modification rate from its carrier. The related federal contract opportunity is a design-build project for site preparation for a dual energy CT being conducted by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
View the file
Other files
Show all 25
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 629-22-135 Site Prep For Dual Energy CT 36C25622R0075
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 .