36C25625R0082 EXHIBIT D.docx
DOCX document 28 KB Posted
- Solicitation number
- 36C25625R0082
About this file
This document is a Contractor Evaluation Form for a Department of Veterans Affairs project (Project No. 667-25-190) involving installation of isolation valves on the domestic water system in Building 1. The form requires potential contractors to provide detailed safety performance information, including:
- Comprehensive safety metrics for 2022-2024, such as total man-hours, OSHA recordable cases, Days Away, Restricted, or Transferred (DART) rate, and any serious OSHA violations. Contractors must submit supporting documentation including OSHA 300 and 300a Forms. 2. Information about the company's Safety and Health Program administrator and 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 and a plan to reduce the rate. The solicitation is specifically issued by the Veterans Health Administration, Veterans Integrated Service Network 16, with the solicitation number 36C25625R0082.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25625R0082 0003.docx | DOCX document | |
| 36C25625R0082 0002.docx | DOCX document | |
| 667-25-190 RFI Register 05142025.docx | DOCX document | |
| 36C25625R0082 0001.docx | DOCX document | |
| 667-25-190 Install Isolation Valvles B1 Sign in Sheet.pdf | ||
| 36C25625R0082 RFP.docx | DOCX document | |
| 36C25625R0082 667-25-190 ISO Valves - Drawings .pdf | ||
| 36C25625R0082 667-25-190 BLDG 1 Asbestos Report .pdf | ||
| 36C25625R0082 EXHIBIT F.docx | DOCX document | |
| 36C25625R0082 EXHIBIT E.docx | DOCX document | |
| 36C25625R0082 667-25-190 Combined Specs 02102025 .pdf | ||
| 36C25625R0082 SOW 667-25-190 02102025.doc | DOC document | |
| 36C25625R0082 WD LA20250031 02282025 .pdf | ||
| 36C25625R0082 EXHIBIT A.docx | DOCX document | |
| 36C25625R0082 EXHIBIT C.docx | DOCX document | |
| 36C25625R0082 667-25-190 Class IV Precautions - ISO Valves .pdf | ||
| 36C25625R0082 667-25-190 ICRA - ISO Valves .pdf |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-25-190 Install Isolation Valves on Domestic Water System, BLDG 1 36C25625R0082
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 .