36C25626R0072 EXHIBIT C- Contractor Evaluation Form Contractor Safety.pdf
PDF 186 KB Posted
- Solicitation number
- 36C25626R0072
About this file
This is a Contractor Evaluation Form for construction safety as part of a federal contract solicitation for the Renovation of Radiation Oncology Department (Project No. 586-26-100, Solicitation No. 36C25626R0072).
The form requires contractors to provide comprehensive safety performance data across three years (2023, 2024, and 2025), including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity (derived from OSHA 300 Forms Column H and I), calculated DART rates (Days Away, Restricted, or Transferred rates using the standard 200,000 multiplier), and the number of serious, willful, or repeat OSHA violations incurred within the preceding three years with supporting explanations for any violations. Contractors must submit copies of OSHA 300 and 300a Forms along with this information. Additionally, the form requests identification of the individual or department administering the company's Safety and Health Program and the company's current Insurance Experience Modification Rate (EMR) obtained directly from the contractor's insurance carrier on carrier letterhead. If the EMR exceeds 1.0, contractors must provide a written explanation from the insurance carrier detailing the reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below. This evaluation form serves as a source selection criterion for assessing contractor safety qualifications.
View the file
Other files
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .