36C25623R0089 EXHIBIT D.docx
DOCX document 31 KB Posted
- Solicitation number
- 36C25623R0089
About this file
This document contains an evaluation form for a construction safety contractor. The form requests information on the contractor's OSHA 300 and 300a forms from 2020 to 2022, including man hours, days away from work cases, and DART rates. It also asks for details on any serious, willful, or repeat OSHA violations in the past three years. The contractor must provide documentation of its OSHA forms and insurance experience modification rate from its carrier. If the EMR exceeds 1.0, an explanation from the carrier is required. The related federal contract opportunity is for project number 502-21-105 to replace the roof on building 2 at a Veterans Affairs medical center. The solicitation is from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25623R0089 0003.docx | DOCX document | |
| 502-21-105 RFI Register 08302023.docx | DOCX document | |
| 36C25623R0089 0002.docx | DOCX document | |
| 502-21-105 Site Visit Sign in Sheet.pdf | ||
| 36C25623R0089 0001.docx | DOCX document | |
| 36C25623R0089 VA - Pineville Lead .pdf | ||
| 36C25623R0089 SOW 07072023 .docx | DOCX document | |
| 36C25623R0089 Combined Specs .pdf | ||
| 36C25623R0089 EXHIBIT B.docx | DOCX document | |
| 36C25623R0089 EXHIBIT A.docx | DOCX document | |
| 36C25623R0089 EXHIBIT F.docx | DOCX document | |
| 36C25623R0089 EXHIBIT C.docx | DOCX document | |
| 36C25623R0089 RFP.docx | DOCX document | |
| 36C25623R0089 WD LA20230051 Mod 5 06162023 .docx | DOCX document | |
| 36C25623R0089 VA Pineville - Asbestos.pdf | ||
| 36C25623R0089 Drawings .pdf | ||
| 36C25623R0089 Clay Tile Size and Color Selection_Redacted.pdf | ||
| 36C25623R0089 502-21-105 BRAND NAME JA 05122023 Redacted.pdf | ||
| 36C25623R0089 PRA v2.pdf | ||
| 36C25623R0089 EXHIBIT E.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. 502-21-105 Replace Roof on BLDG 2 36C25623R0089 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 |
| 2020 |
| 2021 |
| 2022 |
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 .