36C25625R0108 EXHIBIT D.docx
DOCX document 29 KB Posted
- Solicitation number
- 36C25625R0108
About this file
This document is a Contractor Evaluation Form for a construction safety assessment related to a VA Fisher House site preparation project (Solicitation 36C25625R0108). The form requires contractors to provide detailed safety performance information, including OSHA 300 Forms documenting man-hours, workplace injury cases, days away from work, and OSHA violation history for the years 2022-2024. Contractors must also submit their current Insurance Experience Modification Rate (EMR), with special documentation required if the EMR exceeds 1.0. The evaluation aims to assess the safety record and health program administration of potential contractors for the Veterans Health Administration Veterans Integrated Service Network 16 project, with a focus on comprehensive safety documentation and performance metrics.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25625R0108 0002.docx | DOCX document | |
| 36C25625R0108 RFI Registrar 667-23-113 081425.pdf | ||
| 36C25625R0108 0001.docx | DOCX document | |
| 36C25625R0108 Sign in Sheet 667-23-113.pdf | ||
| 36C25625R0108 Combined Drawings.pdf | ||
| 36C25625R0108 ICRA - Fisher House.pdf | ||
| 36C25625R0108 EXHIBIT F.docx | DOCX document | |
| 36C25625R0108 EXHIBIT B.docx | DOCX document | |
| 36C25625R0108 EXHIBIT A.docx | DOCX document | |
| 36C25625R0108.docx | DOCX document | |
| 36C25625R0108 WD LA20250031 022825.pdf | ||
| 36C25625R0108 SPECIFICATIONS FISHER HOUSE OVERTON BROOKS VAMC 6-26-2025.pdf | ||
| 36C25625R0108 EXHIBIT E.docx | DOCX document | |
| 36C25625R0108 EXHIBIT C.docx | DOCX document | |
| 36C25625R0108 SOW - Fisher House 062325.docx | DOCX document |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 667-23-113 CON Site Prep for Fisher House 36C25625R0108 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 .