36C25626R0019 EXHIBIT D.docx
DOCX document 29 KB Posted
- Solicitation number
- 36C25626R0019
About this file
This is a Contractor Evaluation Form for construction safety assessment related to a Pharmacy Physical Security Upgrade project (Solicitation 36C25626R0019) for the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 16.
The form requires contractors to submit detailed safety performance data covering three years (2023-2025), including total man hours worked at jobsites and offices, number of cases involving days away from work or restricted activity, DART rates (Days Away, Restricted, or Transferred), and the count of serious, willful, or repeat OSHA violations. Contractors must provide OSHA 300 and 300a forms as supporting documentation, identify the administrator of their company's Safety and Health Program, and furnish their current Insurance Experience Modification Rate (EMR) from their insurance carrier on carrier letterhead. If the EMR exceeds 1.0, contractors must submit a written explanation from the insurance carrier detailing reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below. This evaluation document serves as part of the source selection process for assessing contractor safety qualifications.
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| 36C25626R0019 0003.docx | DOCX document | |
| 36C25626R0019 0002.docx | DOCX document | |
| Pre-bid conference site visit 4.13.26 sign in.pdf | ||
| WD MS20260051 Hinds.pdf | ||
| 36C25626R0019 0001.docx | DOCX document | |
| 36C25626R0019 EXHIBIT B.docx | DOCX document | |
| 36C25626R0019 To Post.docx | DOCX document | |
| 36C25626R0019 EXHIBIT A.docx | DOCX document | |
| 36C25626R0019 EXHIBIT E.docx | DOCX document | |
| 36C25626R0019 EXHIBIT F.docx | DOCX document | |
| 586-22-105 Specifications Revised.pdf | ||
| Scope of Work Pharmacy Physical security Redlines updated.docx | DOCX document | |
| 586-22-105 Drawings edited tl.pdf | ||
| 010000 11-2021 General Requirements - R2.pdf | ||
| WD MS20260052.pdf | ||
| 36C25626R0019 EXHIBIT C.docx | DOCX document |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 586-22-105 CON Pharmacy Physical Security Upgrade 36C25626R0019
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 |
| 2023 |
| 2024 |
| 2025 |
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 .