36C25622R0084 EXHIBIT D R1.docx
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- Attached to
- Z1DA--CON Project 667-18-111 Abate Central Chase / Replace Fire Main Federal contract opportunity
- Solicitation number
- 36C25622R0084
About this file
This document contains a contractor evaluation form for a construction safety project. The form requests information on a contractor's OSHA 300 and 300a forms from 2019 to 2021, including man hours, days away from work cases, and DART rates. It also asks who administers the contractor's safety program and current EMR insurance rate. Supporting documents requested include OSHA forms, EMR rate on insurer letterhead, and explanations for violations or EMR over 1.0.
The related federal contract opportunity is for project 667-18-111 to abate a central chase and replace a fire main at a Veterans Affairs medical center. The solicitation is posted by the VA Veterans Health Administration VISN 16.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-111 Abate Central Chase and Replace Fire Main 36C25622R0084
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 .