36C25623R0006 - Exhibit A .docx
DOCX document 28 KB Posted
- Attached to
- 36C25623R0006 - Z1DA--Project #667-23-100 Replace Emergency Department Roof (DB) 36C25623R0006
- Solicitation number
- 667-23-100
About this file
This document contains an evaluation form for a construction safety contractor and details of a related federal contract opportunity. The evaluation form requests safety-related information from contractors including man hours, OSHA injury records from 2019 to 2021, documentation of serious violations, and insurance experience modification rates. It also asks who administers the contractor's safety program. The related federal contract opportunity is a solicitation for project number 667-23-100 to replace the emergency department roof at a Veterans Affairs medical center. The solicitation is being conducted by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25623R0006 0001.pdf | ||
| 1675887701205.jpeg | JPEG file | |
| 1675887593466.jpeg | JPEG file | |
| 1675887952406.jpeg | JPEG file | |
| 1675887555487.jpeg | JPEG file | |
| ED ROOF - Aerial View.pdf | ||
| ED ROOF - Sketch.pdf | ||
| RFI Responses.docx | DOCX document | |
| ED ROOF - Aerial Northwest Quarter.pdf | ||
| ED ROOF - Site Grounds Map.pdf | ||
| 1675887647620.jpeg | JPEG file | |
| 1675887841057.jpeg | JPEG file | |
| 1675887758930.jpeg | JPEG file | |
| P09 Revised SOW Replace ED Roof- 667-23-100 09-12-2022.docx | DOCX document | |
| 36C25623R0006 SOLICITATION .pdf | ||
| P09 Class II Precautions - Replace ED Roof 667-23-100 Preliminary.docx | DOCX document | |
| 36C25623R0006 VHA Supplemental Contract Rqts for Combatting COVID-19 (2).docx | DOCX document | |
| 36C25623R0006 - Exhibit B.docx | DOCX document | |
| P09 ICRA - Replace Emergency Department Roof Preliminary.docx | DOCX document |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-23-100 Replace Emergency Department (ED) Roof 36C25623R0006
Exhibit A 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 .