36C25622R0089 EXHIBIT D R1.docx
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- Solicitation number
- 520-22-3-7072-0001
About this file
This document contains a contractor evaluation form for a federal construction project to repair elevators in multiple buildings. The form requests safety information from bidding contractors including OSHA 300 and 300a forms from the previous three years detailing man hours, injury cases, and DART rates. It also asks for explanations of any serious OSHA violations and the insurance experience modification rate from the contractor's carrier. If the rate is over 1.0, an explanation from the carrier is required. The related federal contract opportunity is solicitation number 520-22-3-7072-0001 from the Department of Veterans Affairs for project number 520-22-170 to furnish all labor, tools, materials, and equipment to repair elevators in multiple buildings in Biloxi, Mississippi.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-170 Replace Elevators, Multiple Buildings 36C25622R0089
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 .