36C25623R0096 EXHIBIT D.docx
DOCX document 31 KB Posted
- Attached to
- Replace Chiller # 3 - Pineville, LA - VA (Project No. 502-21-110) Federal contract opportunity
- Solicitation number
- 36C25623R0096
About this file
This document contains an evaluation form for a construction safety contractor for a project to replace Chiller #3 at the Pineville, Louisiana VA facility. The form requests the contractor's OSHA 300 and 300a forms from 2020 to 2022, man hours, cases involving days away from work or restricted activity, DART rate, and any serious, willful, or repeat OSHA violations. It also requests information on who administers the contractor's safety program and the company's current EMR insurance rate on insurer letterhead, including an explanation if over 1.0. The related federal contract opportunity is solicitation number 36C25623R0096 from the Department of Veterans Affairs Veterans Health Administration VISN 16 to replace Chiller #3 in Pineville, LA under project number 502-21-110.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25623R0096 0004.docx | DOCX document | |
| 36C25623R0096 0003.docx | DOCX document | |
| Attachment 2A00002 236400 3-20 Packaged Water Chillers - Addendum 1.pdf | ||
| Attachment 1A00002 - 2023-08-18 Addendum No. 1.pdf | ||
| 36C25623R0096 0002.docx | DOCX document | |
| 36C25623R0096 - Site Visit Sign in Sheet 502-21-110 Aug 15 23.jpg | JPG image | |
| 36C25623R0096 0001.docx | DOCX document | |
| 36C25623R0096 EXHIBIT A.docx | DOCX document | |
| 36C25623R0096 EXHIBIT B.docx | DOCX document | |
| 36C25623R0096 Design Analysis.pdf | ||
| 36C25623R0096 Drawings.pdf | ||
| 36C25623R0096 Specifications.pdf | ||
| 36C25623R0096 EXHIBIT C.docx | DOCX document | |
| 36C25623R0096 EXHIBIT E.docx | DOCX document | |
| PRA 502-21-110 Chiller 3 Replacement - Copy.pdf | ||
| DBA WD LA20220041 Mod 5 (6-16-23).pdf | ||
| 36C25623R0096.docx | DOCX document | |
| 36C25623R0096 EXHIBIT F.docx | DOCX document | |
| Final SOW - Formatted.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. 502-21-110 – Replace Chiller # 3 36C25623R0096 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 .