Attachment E_EXHIBIT A CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.pdf
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- Solicitation number
- 36C25624R0117
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This document is an Exhibit A Contractor Evaluation Form for Construction Safety. The form requires the contractor to provide information about their company's safety records, including OSHA 300 form data, number of OSHA violations, and current Insurance Experience Modification Rate (EMR). The contractor must attach copies of their OSHA 300 and 300a forms. If the EMR is greater than 1.0, the contractor must provide a written explanation from their insurance carrier.
The related federal contract opportunity is for the replacement of fiberglass chilled water piping in Building 170 at the Eugene J. Towbin Veterans Affairs Healthcare Center in North Little Rock, Arkansas. The contract is set aside for Service-Disabled Veteran-Owned Small Businesses (SDVOSB) with a total estimated value between $5,000,000 and $10,000,000. The period of performance is 365 calendar days after the Notice to Proceed is issued. Interested offerors must review the full Request for Proposal (RFP) and associated documents on the SAM.gov website, and submit any questions by the established cut-off date. Only one site visit will be conducted.
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FOR OFFICIAL USE ONLY
Exhibit A 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 .