36C25626R0047 EXHIBIT D.docx
DOCX document 20 KB Posted
- Solicitation number
- 36C25626R0047
About this file
This is a Contractor Evaluation Form for construction safety assessment as part of a solicitation for the Abate Central Chase & Replace Fire Main project at Overton Brooks VA Medical Center. The form is Exhibit D of solicitation 36C25626R0047 and is marked for official use only as source selection sensitive information.
The evaluation form requires contractors to provide three years of occupational safety and health data (2023-2025) including total man hours, number of OSHA reportable cases involving days away from work or restricted activity, calculated DART rates, and counts of serious, willful, or repeat OSHA violations. Contractors must submit supporting documentation including OSHA 300 and 300a forms, identify the individual administering their Safety and Health Program, and provide their current Experience Modification Rate (EMR) from their insurance carrier on carrier letterhead. If the EMR exceeds 1.0, contractors must attach 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 safety-focused evaluation component is designed to assess contractor performance and risk management capabilities for the fire main replacement project.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25626R0047 0003.pdf | ||
| 36C25626R0047 0002.docx | DOCX document | |
| Attachment No. 1 Piping Asbestos Survey.pdf | ||
| Attachment No. 2 Pre-bid Conference Sign-in Sheet.pdf | ||
| Attachment No. 3 WD LA20260031.pdf | ||
| 36C25626R0047 0002.pdf | ||
| 36C25626R0047 0001.pdf | ||
| Abate Central Chase - 13 - ICRA.pdf | ||
| 36C25626R0047 EXHIBIT B.docx | DOCX document | |
| 36C25626R0047 EXHIBIT C.docx | DOCX document | |
| 36C25626R0047.pdf | ||
| Abate Central Chase - 1- SOW.pdf | ||
| Abate Central Chase - 8 - CRA.pdf | ||
| WD LA20260031 01022026.pdf | ||
| Abate Chase - FY26 - Final Drawings.pdf | ||
| Abate Chase - FY26 - IFC Specs - Updated.pdf | ||
| Abate Central Chase - 14 - Class II Precautions.pdf | ||
| 36C25626R0047 EXHIBIT A.docx | DOCX document | |
| 36C25626R0047 EXHIBIT E.docx | DOCX document | |
| 36C25626R0047 EXHIBIT F.docx | DOCX document |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 667-26-111 Abate Central Chase & Replace Fire Main 36C25626R0047
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 .