36C25622R0141 EXHIBIT D R1.docx
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- Solicitation number
- 36C25622R0141
About this file
This document contains a contractor evaluation form for a construction safety company bidding on Project No. 520-22-167 to upgrade mechanical systems. The form requests information on the company'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 company must provide its current insurance experience modification rate from its carrier and an explanation if the rate is over 1.0. It identifies the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16 as the agency and Solicitation Number 36C25622R0141 for the project opportunity to upgrade mechanical systems.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-167 Upgrade Mechanical Systems 36C25622R0141
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 .