Attachment G - Contractor Evaluation Form.pdf
PDF 101 KB Posted
- Attached to
- 598-22-126 Demo Buildings 75, 158, 162, 175, T-166, T-167 (Demo Farm) NLR 36C25624R0004 Amendment 0002
- Solicitation number
- 36C25624R0004
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for demolition services. The form requests information on a contractor's safety record over the past four years, including OSHA incident rates and violations. It also asks for the contractor's NAICS code and details on its safety program administration and insurance experience modification rate. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs to demolish six buildings at its facility in North Little Rock, Arkansas. The solicitation number and amendment information are provided.
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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 .