36C25626R0072 EXHIBIT C- Contractor Evaluation Form Contractor Safety.pdf
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- Attached to
- SOLICITATION | Y1DZ | DESIGN -BUILD | 36C25626R0072 |586-26-100 | RENOVATE RADIATION ONCOLOGY DEPARTMENT
- Solicitation number
- 36C25626R0072_DB_RENOVATE_RADIATION_ONCOLOGY_BUILDING
About this file
This is a Contractor Evaluation Form for Construction Safety, part of the source selection process for Project No. 586-26-100, a Radiation Oncology Department renovation project (Solicitation 36C25626R0072). The form is designated for official use only and contains source selection sensitive information.
The evaluation form requires contractors to submit comprehensive safety documentation across three years (2023, 2024, and 2025), including total man hours for jobsite and office work, the number of cases involving days away from work or restricted activity, calculated DART (Days Away, Restricted, or Transferred) rates, and the number of serious, willful, or repeat OSHA violations within the preceding three years with attached explanations. Contractors must also provide copies of OSHA 300 and 300a Forms. Additionally, the form requests identification of the individual administering the company's Safety and Health Program and the company's current Insurance Experience Modification Rate (EMR) obtained directly from the insurance carrier on letterhead. If the EMR exceeds 1.0, contractors must attach a written explanation from their insurance carrier describing the reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See RFO FAR 2.101 & 3.104 Project
No.586-26-100 RENOVATE RADIATION ONCOLOGY DEPARTMENT 36C25626R0072
Exhibit C 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.
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .