36C25622R0146 EXHIBIT D.docx
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- Attached to
- Z2DA--Project #520-16-102 ER Structural and Foundation Problem, BLDG 3 - BXD (Construction) 36C25622R0146
- Solicitation number
- 36C25622R0146
About this file
This document contains a contractor evaluation form for a structural repair project for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form requests safety information from offerors including man-hours and OSHA injury rates for 2019-2021, any serious violations over the past three years, and copies of OSHA forms. It also asks who administers the company's safety program and its current insurance experience modification rate, requiring an explanation from the carrier if the rate exceeds 1.0. The related federal contract opportunity is solicitation number 36C25622R0146 for Project 520-16-102 ED Structural Repair in Biloxi, Mississippi.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-16-102 ED Structural Repair 36C25622R0146
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 .