36C25625R0126 EXHIBIT D.docx
DOCX document 29 KB Posted
- Attached to
- Z2DA--Project 667-25-190 Install Isolation Valves, B1 (Con) Federal contract opportunity
- Solicitation number
- 36C25625R0126
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 contractors to provide detailed safety and health documentation, including OSHA 300 Forms covering man hours, workplace injury cases, and safety violation history for the years 2022-2024. Contractors must also disclose their current Insurance Experience Modification Rate (EMR), with a requirement to provide explanations if the EMR exceeds 1.0. The evaluation form seeks comprehensive safety performance information to assess the contractor's safety practices and record for a construction project at a Veterans Health Administration facility within Veterans Integrated Service Network 16.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25625R0126 0002.docx | DOCX document | |
| RFI Register 667-25-190_Install Iso Valves 090225.docx | DOCX document | |
| Sign in Sheet 667-25-190.pdf | ||
| 36C25625R0126 0001.docx | DOCX document | |
| 36C25625R0126 667-25-190 Combined Specs 02102025.pdf | ||
| 36C25625R0126 667-25-190 Class IV Precautions - ISO Valves .pdf | ||
| 36C25625R0126 EXHIBIT E.docx | DOCX document | |
| 36C25625R0126 667-25-190 ISO Valves - Drawings.pdf | ||
| 36C25625R0125 WD LA20250031 070425.pdf | ||
| 36C25625R0126 EXHIBIT F.docx | DOCX document | |
| 36C25625R0126 EXHIBIT C.docx | DOCX document | |
| 36C25625R0126 EXHIBIT A.docx | DOCX document | |
| 36C25625R0126 667-25-190 BLDG 1 Asbestos Report.pdf | ||
| 36C25625R0126 667-25-190 ICRA - ISO Valves.pdf | ||
| 36C25625R0126 667-25-190 SOW 02102025 .doc | DOC document | |
| 36C25625R0126.docx | DOCX document |
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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 36C25625R0126
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 .