Contractor Evaluation Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C25625R0014
About this file
This is a Contractor Evaluation Form focused on construction safety performance metrics and documentation. The form requires contractors to provide three years of safety data (2021-2023) from OSHA 300 Forms, including man hours worked, cases involving days away from work or restricted activity, and DART rates (Days Away, Restricted, or Transferred). Contractors must report any serious, willful, or repeat OSHA violations from the past three years with explanations.
The form is associated with a VA solicitation (36C25625R0014) for a Roof Warehouse & Mental Health Modular project at Jackson VAMC. Required documentation includes OSHA 300 and 300a Forms, identification of Safety and Health Program administrator, and current Insurance Experience Modification Rate (EMR) with carrier documentation. If EMR exceeds 1.0, contractors must provide written explanation from their insurance carrier including anticipated reduction timeline.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25625R0014 0005.docx | DOCX document | |
| Scope of Work_Revised 1-6-2025 AMENDMENT 0005.pdf | ||
| 36C25625R0014 0004.docx | DOCX document | |
| 36C25625R0014 0003.docx | DOCX document | |
| Scope of Work_Revised 1-6-2025.pdf | ||
| 36C25625R0014 0002.docx | DOCX document | |
| 36C25625R0014_0001.docx | DOCX document | |
| 586-26-102 Pre-bid RFIs_Responses.docx | DOCX document | |
| Jackson VA Asbestos Report April 2022.pdf | ||
| Site Visit Sign In Sheet 586-26-102.doc.pdf | ||
| Past and Present Performance Questionnaire.docx | DOCX document | |
| Wage Determination MS20240075.pdf | ||
| 36C25625R0014_1.pdf | ||
| SOW_586-26-102 - Final.pdf | ||
| Specifications.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 .