36C25622R0088 EXHIBIT D.docx
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- Solicitation number
- 36C25622R0088
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This document contains a contractor evaluation form for a construction project. The form requests safety information including man hours, OSHA injury rates, violations, and insurance experience modification rates from prospective contractors bidding on Project No. 629-18-115 to install signs and striping for garages for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. Contractors must provide details on cases involving days away from work and restricted activity from 2019 to 2021 using OSHA 300 forms, as well as explanations for any serious OSHA violations in the last three years. Copies of OSHA 300 and 300a forms and documentation of insurance experience modification rates are also required.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 629-18-115 Install Signs and Striping for Garages 36C25622R0088
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 .