598-20-106 EXHIBIT B CONTRACTOR EVALUATION FORM.pdf
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- Solicitation number
- 36C25624R0087
About this file
This document is a Contractor Evaluation Form for a construction safety contract opportunity with the Department of Veterans Affairs (VA) at the Eugene J. Towbin Memorial Veterans Hospital in North Little Rock, Arkansas.
The form requires the contractor to provide information about their company's safety record, including OSHA 300 form data, number of OSHA violations, and current Insurance Experience Modification Rate (EMR). The EMR must be obtained from the contractor's insurance carrier and provided on the carrier's letterhead. If the EMR is greater than 1.0, an explanation is required.
The related federal contract opportunity is for the renovation of approximately 16,000 square feet of the hospital's existing Physical Medicine and Rehabilitation Service (PMRS) space. The work will be completed in two phases and incorporate Planetree principles, VA Space and Equipment Planning System (VA SEPS) requirements, and comply with all applicable codes and standards. Key aspects include demolition, new construction, engineering system modifications, and infection control measures.
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FOR OFFICIAL USE ONLY
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 .