Attachment F - Contractor Evaluation Form.pdf
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- Solicitation number
- 36C25624R0005
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for renovation services. The evaluation form requests information on a contractor's OSHA 300 forms including man hours, injury cases, and DART rates for the past four years. It also asks for NAICS code, safety program administrator, and experience modification rates. Contractors must submit the completed form along with OSHA 300 and 300A forms, and an explanation for any serious, willful, or repeat OSHA violations. The related federal contract opportunity is solicitation number 36C25624R0005 from the Department of Veterans Affairs for renovations to ground floor services at a Veterans Health Administration facility. It provides further context regarding the type of construction and renovation services required but no additional details on response dates, pricing, or other contract terms.
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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 .