36C25625R0003 EXHIBIT D.docx
DOCX document 28 KB Posted
- Solicitation number
- 36C25625R0003
About this file
This document is a Contractor Evaluation Form for a Department of Veterans Affairs (VA) contract (Solicitation Number 36C25625R0003) related to JACC Chilled Water Piping Repair. The form requires potential contractors to provide detailed safety and health information, including OSHA documentation for the years 2022-2024. Specifically, contractors must submit their total man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and any OSHA violations from the past three years.
The form mandates additional documentation, including OSHA 300 and 300a Forms, and requires contractors to disclose who administers their Safety and Health Program and their current Insurance Experience Modification Rate (EMR). If a contractor's EMR exceeds 1.0, they must provide a written explanation from their insurance carrier detailing the reasons for the higher rate and a projected timeline for reducing it. The solicitation is associated with the Veterans Health Administration's Veterans Integrated Service Network 16, suggesting this is a safety-critical infrastructure repair project for a VA medical facility.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25625R0003 0003.docx | DOCX document | |
| 36C25625R0003 0002.docx | DOCX document | |
| 520-25-107 Site Visit Sign in Sheet.pdf | ||
| 36C25625R0003 0001.docx | DOCX document | |
| 36C25625R0003-520-25-107 -Specifications -01-22-2025 .pdf | ||
| 36C25625R0003-Contracting Only ICRAs and PCRAs Repair JACC Chilled Water Piping .pdf | ||
| 36C25625R0003 EXHIBIT E.docx | DOCX document | |
| 36C25625R0003 EXHIBIT C.docx | DOCX document | |
| 36C25625R0003 EXHIBIT B.docx | DOCX document | |
| P07 Wage Determination FL20250203 03-14-2025.pdf | ||
| Site Visit Instructions - 520-25-107-Repair JACC Chilled Water Piping v2.pdf | ||
| SOW Repair JACC Chilled Water Piping -New 03-20-2025.pdf | ||
| 36C25625R0003-Drawings Repair JACC chilled water piping .pdf | ||
| 36C25625R0003 Brand Name JA-Redacted.pdf | ||
| 36C25625R0003.docx | DOCX document | |
| 36C25625R0003 EXHIBIT F.docx | DOCX document | |
| 36C25625R0003 EXHIBIT A.docx | DOCX document |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 520-25-107 CON Repair JACC Chilled Water Piping 36C25625R0003
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 |
| 2022 |
| 2023 |
| 2024 |
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 .