36C25624R0055 EXHIBIT D.docx
DOCX document 29 KB Posted
- Solicitation number
- 667-24-120
About this file
This document is a Contractor Evaluation Form related to a federal contract opportunity to Renovate for VA Kids Care. The form requires the contractor to provide information about their safety record, including OSHA 300 form data, number of safety violations, and their current Insurance Experience Modification Rate (EMR). The contractor must also identify who administers their safety and health program. This information will be used to evaluate the contractor's safety performance as part of the solicitation requirements for the project. The related federal contract opportunity is for a design-build project to renovate a facility, with the Solicitation Number 667-24-120 and an agency of Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25624R0055 0001.docx | DOCX document | |
| SOW - Renovate for VA Kids Care 6-10-24.docx | DOCX document | |
| 667-24-120 VA Kids Care RFI Register 06132024.docx | DOCX document | |
| 667-081 OUTPATIENT MH IMPR_BSMNT AND 1st FLOOR AS-BUILTS A101.pdf | ||
| SOW Attachment 2 - VA Kids Care Space Design Guide.pdf | ||
| 36C25624R0055 SOW 667-24-120 022224.docx | DOCX document | |
| SOW Attachment 3 - Final Response to VCAP PSRDM Deviation Request.pdf | ||
| 36C25624R0055 EXHIBIT A.docx | DOCX document | |
| 36C25624R0055 EXHIBIT B.docx | DOCX document | |
| 36C25624R0055 EXHIBIT E.docx | DOCX document | |
| 36C25624R0055 EXHIBIT F.docx | DOCX document | |
| 36C25624R0055 EXHIBIT C.docx | DOCX document | |
| SOW Attachment 1 - Program for Design.pdf | ||
| 36C25624R0055 RFP.docx | DOCX document | |
| 36C25624R0055 WD LA20240031 Mod 01052024.pdf |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-24-120; Renovate for VA Kids Care 36C25624R0055
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 .