36C25625R0001 EXHIBIT D.docx
DOCX document 28 KB Posted
- Solicitation number
- 36C25625R0001
About this file
This is a Contractor Evaluation Form (Exhibit D) focused on construction safety documentation requirements for Project No. 502-17-102 Replace Roof & HVAC Building 9 at the Department of Veterans Affairs. The form requires contractors to provide detailed safety performance data from their OSHA 300 Forms for 2021-2023, including man-hours worked, cases involving days away from work, DART rates, and any OSHA violations.
Contractors must submit copies of OSHA 300 and 300a Forms, identify their Safety and Health Program administrator, and provide their current Insurance Experience Modification Rate (EMR) on insurance carrier letterhead. If the EMR exceeds 1.0, a written explanation from the insurance carrier is required detailing reasons and anticipated reduction timeline. This form appears to be part of a larger solicitation package (36C25625R0001) for the Veterans Integrated Service Network 16.
View the file
Other files
Show all 46
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. 502-17-102 Replace Roof & HVAC BLDG 9 36C25625R0001 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 .