36C25624R0012 - Exhibit B.docx
DOCX document 29 KB Posted
- Solicitation number
- 36C25624R0012
About this file
This document contains an evaluation form for a construction safety contractor submitting a proposal for a Department of Veterans Affairs project to install access platforms for exhaust fans. The form requests the contractor's OSHA 300 and 300a forms from 2020 to 2022, detailing man hours, injury cases, days away from work rates, and any serious violations. It also asks who administers the company's safety program and the current insurance experience modification rate, requiring an explanation from the carrier if above 1.0. The related federal contract opportunity is solicitation number 36C25624R0012 for exhaust fan platform installation at a Veterans Health Administration research facility.
View the file
Other files
Show all 13
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 629-22-111 D/B Installation of Access Platforms for Exhaust Fans 12 A and B 36C25624R0012
Exhibit B 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 .