564-17-140 EXHIBIT B CONTRACTOR EVALUATION FORM.pdf
PDF 99 KB Posted
- Solicitation number
- 36C25624R0024
About this file
This document contains a contractor evaluation form and details of a related federal contract opportunity to renovate an inpatient medical/surgical unit. The evaluation form requests safety-related information from offerors such as OSHA 300 and 300A forms from the previous three years detailing man-hours, injury cases, and violation rates. It also asks for the name of the offeror's safety program administrator and current insurance experience modification rate verified by its carrier. The related federal contract opportunity is solicitation number 36C25624R0024 issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16 to renovate Medical/Surgical Unit 2B. Offerors are required to provide the safety documentation and disclosures requested in the contractor evaluation form as part of their proposal.
View the file
Other files
Show all 21
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
564-17-140 Renovate Med/Surg Unit 2B Exhibit B
Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023 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 .