A0003_copy Attachment E_EXHIBIT A CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.pdf
PDF 56 KB Posted
- Solicitation number
- 36C25624R0117
About this file
This document appears to be an Exhibit A Contractor Evaluation Form Construction Safety for a federal contract opportunity. It requests information on the company's OSHA 300 forms and safety record, including number of man-hours, DART rate, and any OSHA violations. It also asks for details on who administers the company's safety and health program, as well as the current Insurance Experience Modification Rate (EMR).
The related federal contract opportunity is for the replacement of fiberglass chilled water piping in Building 170 at the Eugene J. Towbin Veterans Affairs Healthcare Center in North Little Rock, Arkansas. The contract will be a 100% Set-Aside for Service-Disabled Veteran-Owned Small Businesses (SDVOSB), with an estimated contract value between $5,000,000 and $10,000,000. The anticipated contract award date is approximately 30 days or less after receipt of proposals, with a period of performance of 365 calendar days after issuance of the Notice to Proceed.
View the file
Other files
Show all 14
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
Exhibit A 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 .