Attachment E - Contractor Evaluation Form.pdf
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- Solicitation number
- 36C25623R0080
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity with the Department of Veterans Affairs. The evaluation form requests information on a contractor's OSHA 300 forms including man hours, cases involving days away from work or restricted activity, DART rate, and any serious, willful, or repeat OSHA violations from the past three years. It also asks for the contractor's NAICS code and who administers their safety and health program. Contractors must have an experience modification rate of 1.0 or below. The federal contract opportunity is for replacing four air handling units at the JLM Veterans Medical Center and was solicited with proposal number 36C25623R0080.
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Text version
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 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 explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)
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. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .