Contractor Evaluation Form.docx
DOCX document 28 KB Posted
- Solicitation number
- 36C25625R0026
About this file
This is a Contractor Evaluation Form focused on construction safety metrics and documentation requirements. The form requests detailed safety performance data spanning 2022-2024, including man-hours worked, cases involving lost work days or restricted activity, DART rates, and OSHA violations. Contractors must provide OSHA 300 and 300a Forms and their current Insurance Experience Modification Rate (EMR) on insurance carrier letterhead, with additional explanation required if the EMR exceeds 1.0.
The form is associated with VA solicitation 36C25625R0026 for upgrading switchgear electronic components at Buildings 27 and 29 at the Fayetteville Veterans Health System Organization, under Veterans Integrated Service Network 16. The evaluation form appears to be part of the contractor qualification process for this construction project.
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| 564-23-503 - PRE-BID RFIs - COMPLETE.docx | DOCX document | |
| 564-23-503 Pre-Bid Site Visit Sign In Sheet 02.04.2025.pdf | ||
| 36C25625R0026 0001.docx | DOCX document | |
| 564-23-503 SOW R5.docx | DOCX document | |
| LV Generator Wiring Diagram.pdf | ||
| Past and Present Performance Questionnaire.docx | DOCX document | |
| Washington County Wage Determination.docx | DOCX document | |
| Site Plan Map.pdf | ||
| Kohler Low Voltage Switchgear Operation Manual.pdf | ||
| 36C25625R0026 SOLICITATION.docx | DOCX document | |
| Combined Specifications R4.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 |
| 2022 |
| 2023 |
| 2024 |
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 .