36C25624R0109 EXHIBIT D.docx
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- Solicitation number
- 36C25624R0109
About this file
This document is a Contractor Evaluation Form related to Solicitation Number 36C25624R0109 for the Upgrade Isolation Wards Room Exhaust System project. The form requests the offeror to provide information on their safety record, including the number of man hours, cases involving days away from work, their DART rate, and any OSHA violations within the last 3 years. The offeror is also required to provide their current Insurance Experience Modification Rate (EMR) from their insurance carrier, and if the EMR is greater than 1.0, to attach a written explanation describing the reasons and anticipated date for reduction. The project is being procured by the Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 16.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-25-125 Upgrade Isolation Wards Room Exhaust System 36C25624R0109 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.
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