Contractor Evaluation Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C25625R0015
About this file
This is a Contractor Evaluation Form focused on construction safety records and performance. The form requires contractors to provide detailed safety statistics from their OSHA 300 Forms for years 2021-2023, including man-hours worked, cases involving days away from work or restricted activity, and DART (Days Away, Restricted, or Transferred) rates.
The form is associated with a VA pharmacy physical security upgrade project (Solicitation #36C25625R0015) at Jackson VAMC. Contractors must submit their current Insurance Experience Modification Rate (EMR) on insurance carrier letterhead, with additional explanation required if the EMR exceeds 1.0. The form also requests information about who administers the company's Safety and Health Program and requires copies of OSHA 300 and 300a Forms, along with explanations for any serious, willful, or repeat OSHA violations from the past three years.
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Other files
| File | Type | Posted |
|---|---|---|
| 586-22-105 - PRE-BID RFIs - COMPLETE.docx | DOCX document | |
| EXHIBIT A PERFORMANCE RELEVANCY SURVEY - 586-22-105.pdf | ||
| 586-22-105 Pharmacy Physical Security Upgrade Sign-in Sheet.pdf | ||
| Regulated Building Materials Survey Report.pdf | ||
| 36C25625R0015 0001.docx | DOCX document | |
| 36C25625R0015_RFP Document.docx | DOCX document | |
| 586-22-105 Specifications.pdf | ||
| Past and Present Performance Questionnaire.docx | DOCX document | |
| Wage Determination MS20240075.pdf | ||
| SOW_Pharmacy Physical Security Upgrade.docx | DOCX document | |
| 586-22-105 Drawings.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 .