Attachment E - Contractor Evaluation Form.pdf
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- Attached to
- 36C25623R0081 Amendment 0007_598-19-118 Replace 21 AHUs and Chiller for AHU-18 at NLR (VA-23-00058622)
- Solicitation number
- 36C25623R0081
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for HVAC services. The evaluation form requests information on a contractor's safety record, including OSHA forms, injury rates, violations, and insurance experience modification rates over three years. Contractors must submit the completed evaluation form along with proposals to qualify for an HVAC services contract with the Department of Veterans Affairs to replace air handling units and chillers at a Veterans facility. The solicitation provides additional details on the required HVAC upgrade work, with a response deadline of March 2023 and period of performance through 2025. Insurance and safety qualifications appear mandatory for consideration under this opportunity.
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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 .