36C25626R0117 EXHIBIT D Safety Form.docx
DOCX document 32 KB Posted
- Solicitation number
- 36C25626R0117
About this file
This is an Exhibit D Safety Form for a federal construction project related to suicide risk mitigation fencing at a Department of Veterans Affairs facility under VISN 16 (Veterans Integrated Service Network 16). The form is a template document designed to capture and standardize safety requirements and procedures that contractors must comply with during the execution of the project.
The form serves as a mandatory safety documentation appendix to the Request for Proposals (RFP) 36C25626R0117 for Project 629-25-104 ED Suicide Risk Mitigation Fence. As a safety form template, it establishes the framework for contractors to document their safety protocols, certifications, training requirements, and compliance measures related to the construction and installation of suicide risk mitigation fencing at a Veterans Affairs facility. Contractors responding to this solicitation would be required to complete and submit this form as part of their proposal package, demonstrating their commitment to and capability for maintaining appropriate safety standards throughout project execution.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Wage Determination.txt | TXT text file | |
| 629-25-104 Emergency Dept Suicide Risk Mitigation Fence SOW.pdf | ||
| 36C25626R0117 EXHIBIT A Past Performance Relevancy.docx | DOCX document | |
| 36C25626R0117 EXHIBIT C Subcontractor Information Consent.docx | DOCX document | |
| 36C25626R0117.docx | DOCX document | |
| 2515 VA New Orleans ED Fence - SPECIFICATIONS - BD revised 13 July 2026.pdf | ||
| DOL Wage Determination LA20260041.pdf | ||
| TMM 2515_Architecture_BID DOCUMENTS.pdf | ||
| 36C25626R0117 EXHIBIT E Surety Form.docx | DOCX document | |
| 36C25626R0117 EXHIBIT F Request for Information.docx | DOCX document |
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 FAR 2.101 & 3.104 Project No. 629-25-104 Emergency Department Suicide Risk Mitigation Fence 36C25626R0117
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 |
| 2024 |
| 2025 |
| 2026 |
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 .