36C25622R0090 EXHIBIT D.docx
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- Solicitation number
- 36C25622R0090
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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 for explanations of any serious OSHA violations in the last three years. The contractor must provide copies of the OSHA forms and identify who administers its safety and health program. The contractor is also required to disclose its current insurance experience modification rate from its carrier, and explain any rate over 1.0. The related federal contract opportunity is for connecting condenser pumps to emergency power for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 629-18-119 Connect Condenser Pumps to Emergency Power 36C25622R0090 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 .