36C25625R0067 EXHIBIT D.docx
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- Solicitation number
- 36C25625R0067
About this file
This document is a Contractor Evaluation Form for a roof and window replacement project (Project No. 502-21-118) issued by the Department of Veterans Affairs Veterans Health Administration. The form requires potential contractors to provide detailed safety and health information, including:
- Three years of comprehensive safety data (2022-2024), such as man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and OSHA violations. Contractors must submit OSHA 300 and 300a Forms and provide explanations for any serious, willful, or repeat violations. 2. Contractors must identify who administers their Safety and Health Program and provide their current Insurance Experience Modification Rate (EMR), with additional documentation required if the EMR exceeds 1.0. The solicitation (36C25625R0067) specifically involves replacing the roof and windows of Building 4 for 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. 502-21-118 Replace Roof and Windows of Bldg 4 36C25625R0067 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 .