36C25626R0023 EXHIBIT D.docx
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- Solicitation number
- 36C25626R0023
About this file
This file is a Contractor Evaluation Form for construction safety, serving as Exhibit D to solicitation 36C25626R0023 for the Department of Veterans Affairs Veterans Health Administration. The form requires contractors to submit detailed occupational safety and health information covering three years (2023-2025), including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity, calculated DART rates (days away, restricted, or transferred rates), and any serious, willful, or repeat OSHA violations incurred during the past three years with accompanying explanations.
Contractors must provide supporting documentation including OSHA 300 and 300a Forms, identify the individual administering their company's Safety and Health Program, and submit their current Insurance Experience Modification Rate (EMR) obtained directly from their insurance carrier on carrier letterhead. If the EMR exceeds 1.0, contractors must attach a written explanation from their insurance carrier detailing the reasons for the elevated rate and providing an anticipated date for reduction to 1.0 or below. This evaluation form is part of the solicitation for replacing underground 15kV feeders and transformers at a Veterans Integrated Service Network 16 facility in North Little Rock (NLR).
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 598-19-112 CON 15KV Feeder Loop 36C25626R0023
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 .