36C25622R0092 - Exhibit D - Contractor Evaluation Form Construction Safety.docx
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- Attached to
- Y1JZ--Project No. 520-22-177 Construct Three-Sided EMPI Structure Biloxi, MS Federal contract opportunity
- Solicitation number
- 36C25622R0092
About this file
This document contains a contractor evaluation form for construction safety related to Solicitation Number 36C25622R0092 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form requests contact information and safety data from offerors including man hours, OSHA recordable incidents, days away from work rates, and serious violations over the past three years. It also asks who administers the company's safety program and its current insurance experience modification rate, requiring an explanation if the rate exceeds 1.0. Offerors must attach the requested OSHA forms and documentation of their insurance rate. The solicitation involves Project No. 520-22-177 to construct a three-sided EMPI structure in Biloxi, Mississippi.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 520-22-177 Construct Three-Sided EMPI Structure 36C25622R0092
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 .