36C25622R0123 EXHIBIT D.docx
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- Z1DA--Project #520-22-174 Access Control and Security System Upgrades and Misc Interior Improvements-Construction - 36C25622R0123 Federal contract opportunity
- Solicitation number
- 520-22-174
About this file
This document contains a contractor evaluation form for a construction project. The federal agency soliciting responses is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The project involves access control, security system upgrades, and miscellaneous interior improvements. Contractors are required to provide safety records including OSHA 300 and 300a forms from the past three years, insurance experience modification rates, and explanations for any serious violations or EMR rates above 1.0. The form also requests information on who administers the contractor's safety and health program and total man hours from the past three years.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-174 Access Control, Security System Upgrades & Miscellaneous Interior Improvements 36C25622R0123
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.
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