36C25623R0109 EXHIBIT D.docx
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- Attached to
- Renovate Interior Space JACC Federal contract opportunity
- Solicitation number
- 520-23-106
About this file
This document contains a contractor evaluation form for the solicitation to renovate interior space at a Joint Ambulatory Care Center. The form requests safety and health information from offerors, including man hours and OSHA recordable incident rates for the past three years. It also asks who administers the company's safety program and its current insurance experience modification rate, requiring an explanation if the rate exceeds 1.0. The related federal contract opportunity is for renovating interior space at a Veterans Health Administration facility under Solicitation Number 520-23-106 by the Department of Veterans Affairs Veterans Integrated Service Network 16.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-23-106 Renovate Interior Space JACC 36C25623R0109
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.
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