CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY v2.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C25621R0139
About this file
This document contains a contractor evaluation form and details of a related federal contract opportunity for construction services. The contractor evaluation form requests safety-related information from contractors over three years, including OSHA forms, injury rates, violations, and insurance rates. The federal contract opportunity is a 100% set-aside for service-disabled veteran-owned small businesses issued by the Department of Veterans Affairs to install flooring and expansion joints at a Veterans Health Care facility in Arkansas. The solicitation number is provided, along with details on the project scope, applicable NAICS code, size standard, construction cost range, response date, and verification requirements for interested SDVOSB concerns.
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| AMENDMENT 36C25621R0139 0002.docx | DOCX document | |
| SOW 564-19-601 New Flooring to replace ceramic tile and Expansion joints r3 Adding 2 EJ (002).docx | DOCX document | |
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| 564-19-601 Drawings Binded R2 with 2 EJ.pdf | ||
| AMENDMENT 36C25621R0139 0001.docx | DOCX document | |
| 564-19-601 Drawings Binded A0001.pdf | ||
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| 36C25621R0139 - SOLICITATION.docx | DOCX document | |
| 564-19-601 Drawings Binded (2).pdf | ||
| WAGE DETERMINATION AR20210035 01-01-2021.pdf |
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Text version
FOR OFFICIAL USE ONLY
Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
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.
File details come from the government source that posted it. Updated .