36C25622R0094 EXHIBIT D.docx
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- Attached to
- Z2DA--Project #502-19-107 - Replace AHU-104 - Construction - 36C25622R0094 Federal contract opportunity
- Solicitation number
- 502-19-107
About this file
This document contains a contractor evaluation form for a construction safety project. The form requests information on a construction company's safety record over the past three years, including total man hours, OSHA injury reports, and any serious violations. It also asks for the company's current insurance experience modification rate and safety program administrator.
The related federal contract opportunity is a solicitation from the Department of Veterans Affairs for project number 502-19-107 to replace an air handling unit at a Veterans Health Administration facility. The opportunity type is listed as a solicitation and no further details are provided in the document excerpt given.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 502-19-107 Replace AHU 104 36C25622R0094
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 .