Contractor Evaluation Form.docx
DOCX document 27 KB Posted
- Attached to
- Z1LZ--586-24-100 | Repair Parking Lots and Roads
- Solicitation number
- 36C25624R0014
About this file
This document contains a contractor evaluation form for a construction safety company as well as details of a related federal contract opportunity for repairing parking lots and roads at a Veterans Affairs medical center. The evaluation form requests safety-related information and documentation from contractors over the past three years, including man-hours, OSHA recordable incidents, incident rates, and violations. It also asks for the identity of the company's safety administrator and current insurance experience modification rate. The related federal contract opportunity is solicited through the Department of Veterans Affairs with a solicitation number provided. The opportunity is for repairing parking lots and roads at the Jackson VAMC as detailed in the attached solicitation and supporting documents.
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Other files
| File | Type | Posted |
|---|---|---|
| Revised Proposal Preparation and Evaluation Information.docx | DOCX document | |
| Pre-Bid Site Visit Attendance Sheet.pdf | ||
| Pre-Bid Site Visit Attendance Sheet.pdf | ||
| Estimated Quantities.pdf | ||
| Site Drawing.pdf | ||
| SCOPE OF WORK_Final.docx | DOCX document | |
| PRE-BID RFIs and Responses.docx | DOCX document | |
| 36C25624R0014 0003.docx | DOCX document | |
| Scope of Work_Revision 2_586-24-100.pdf | ||
| 36C25624R0014 0002.docx | DOCX document | |
| Scope of Work_Revision 2_586-24-100.pdf | ||
| Revised Scope of Work_586-24-100.pdf | ||
| 901-S-401 Asphalt Specification.pdf | ||
| 36C25624R0014 0001.docx | DOCX document | |
| 586-24-100 Statement of Work.docx | DOCX document | |
| 36C25624R0014_RFP.docx | DOCX document | |
| 36C25624R0014_1.docx | DOCX document | |
| Past and Present Performance Questionnaire.docx | DOCX document | |
| Wage Determination.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 |
| 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.
File details come from the government source that posted it. Updated .