36C25626R0064 EXHIBIT D.docx

This is a Contractor Evaluation Form, specifically an exhibit document used for source selection purposes in the solicitation for Replacement Underground Water Tanks (Solicitation Number 36C25626R0064) issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form does not address specific products or services required; rather, it serves as an appendix establishing evaluation criteria for contractor qualification and safety performance assessment.

The evaluation form requires contractors to submit detailed occupational safety and health information across a three-year period (2022-2024), including total man hours worked at jobsites and offices, recordable cases involving days away from work or restricted activity, and calculation of DART (Days Away, Restricted, or Transferred) rates using the standard OSHA metric of cases multiplied by 200,000 divided by total man hours. Contractors must also disclose the number of serious, willful, or repeat OSHA violations within the past three years with accompanying explanations, provide copies of OSHA 300 and 300a Forms, identify the administrator of their Safety and Health Program, and submit their current Insurance Experience Modification Rate (EMR) on insurance carrier letterhead. If the EMR exceeds 1.0, contractors must provide a written explanation from their insurance carrier detailing reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below. This information will be used to evaluate contractors' safety performance and risk management capabilities during the source selection process.