Construction Safety Form.docx

FOR OFFICIAL USE ONLY

Source Selection Sensitive Information—See FAR 2.101 & 3.104

CONTRACTOR EVALUATION FORM

CONSTRUCTION SAFETY

Instructions to Offeror: Complete the information and send this document with your RFP.

PART 1. Past and Present Contracts: Provide any past or current contracts that you have completed in the last 5 years that are relevant to this project. You may make additional sheets but do not list more than 20 contracts. Provide all information requested regarding YOUR PERFORMANCE on the contracts you elect to reference.

Yes or No Any Serious Safety or OSHA Violations Yes or No

(NOTE: Please provide a narrative below on any projects that you indicated yes to an OSHA or Serious Safety Violation.)

Provide detailed description of the work performed the violation and what remedy or action was taken.

1. Contract: __________________________

Violation and what corrective action was taken:

Point of Contact of References you would like the source selection team to contact about this project:

Name: ________________________ Title: ________________________ Agency: ________________________ Email: ________________________ Phone: ________________________

2. Contract: __________________________

Point of Contact of References you would like the source selection team to contact about this project:

Title: ________________________ Agency: ________________________ Email: ________________________ Phone: ________________________

3. Contract: __________________________

Point of Contact of References you would like the source selection team to contact about this project:

Title: ________________________ Agency: ________________________ Email: ________________________ Phone: ________________________