36C25622R0086 EXHIBIT D R1.docx
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- Solicitation number
- 36C25622R0086
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This document contains a contractor evaluation form for a federal construction project to replace various roofs. The form requests safety-related information from contractors including man-hours and OSHA recordable incident rates for the past three years. It also asks contractors to provide documentation of their current OSHA forms, safety program administration, and insurance experience modification rate from their carrier. The related federal contract opportunity is for Project 667-18-104 to replace a roof through the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. Contractors are to provide safety performance history and documentation to be evaluated for this roof replacement project.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-104 Replace Various Roofs 36C25622R0086
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 .