36C25624R0052 EXHIBIT D.docx
DOCX document 42 KB Posted
- Solicitation number
- 36C25624R0052
About this file
This document contains a contractor evaluation form and requests safety information from offerors for a mechanical systems upgrade project. The form requests offerors to provide man-hours and OSHA recordable incident rates for the past three years from their OSHA 300 forms. It also requests information on serious OSHA violations and a copy of the OSHA 300 forms. Offerors are asked to provide details on their safety and health program administration and current insurance experience modification rate from their carrier. If the modification rate is over 1.0, an explanation is requested.
The related federal contract opportunity notice is for Project 520-22-169 to upgrade mechanical systems at the Joint Ambulatory Care Clinic in Pensacola, FL, the Magnolia Clinic in Panama City Beach, FL, and the Eglin Air Force Base VA Clinic in Eglin AFB, FL. The solicitation number is 36C25624R0052 and it is a pre-solicitation notice issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
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Other files
| File | Type | Posted |
|---|---|---|
| Full Drawing Set Final.pdf | ||
| 36C25624R0052 EXHIBIT B.docx | DOCX document | |
| WD Okaloosa County FL20240217.pdf | ||
| P03 Brand Name JA 520-22-169 (CO Signed) - Copy_Redacted.pdf | ||
| 36C25624R0052 EXHIBIT E.docx | DOCX document | |
| Attachment_A_Basis of Design Submittals rev1.pdf | ||
| 36C25624R0052 EXHIBIT F.docx | DOCX document | |
| 36C25624R0052 EXHIBIT A.docx | DOCX document | |
| 36C25624R0052 Solicitation.pdf | ||
| Attachment_B_Decon Site Prep.pdf | ||
| WD Bay County FL20240005.pdf | ||
| ICRA JACC Mechanical Upgrade Contract ONLY.pdf | ||
| P09 (REVISED) 520-22-169 SOW Upgrade Mech Systems JACC Eglin PCY rev4.docx | DOCX document | |
| WD Escambia County FL20240203.pdf | ||
| 36C25624R0052 EXHIBIT C.docx | DOCX document | |
| Specs rev6.pdf | ||
| 36C25624R0052 Pre-solicitation.docx | DOCX document | |
| P09 (REVISED) 520-22-169 SOW Upgrade Mechanical Systems JACC Eglin PCY rev4.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. 520-22-169 Upgrade Mechanical Systems 36C25624R0052
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 |
| 2021 |
| 2022 |
| 2023 |
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 .