36C25623R0012 EXHIBIT D.docx

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Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-178 Correct FCA Deficiencies 36C25623R0012

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:

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.

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.