36C25626R0031 EXHIBIT D.docx

This is a Contractor Evaluation Form that serves as Exhibit D to a Request for Proposals (RFP) for construction services related to wayfinding and signage replacement. The form is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16 for solicitation number 36C25626R0031, Project No. 502-23-707.

The evaluation form requires contractors to submit detailed safety and health information for assessment purposes. Specifically, contractors must provide OSHA 300 and 300A Forms for calendar years 2023, 2024, and 2025, documenting total man hours (jobsite and office), number of cases involving days away from work or restricted activity, and calculated DART rates (Days Away, Restricted, or Transferred). Contractors must also disclose any serious, willful, or repeat OSHA violations from the past three years with supporting explanations. Additionally, contractors are required to identify the individual responsible for administering their company's Safety and Health Program and provide their current Insurance Experience Modification Rate (EMR) on their insurance carrier's 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 form template does not address specific products, services, pricing terms, response dates, or award dates; it is exclusively a safety and experience evaluation document for contractor qualification purposes.