Contractor Evaluation Safety Form.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--402-23-102, Medical Gas System Upgrade
- Solicitation number
- 36C24123R0150
About this file
This document contains a pre-award contractor evaluation form for a federal contract opportunity for a medical gas system upgrade at a Veterans Affairs medical facility. The form requests information on the contractor's safety record over the past three years, including total man hours, OSHA-reportable injuries, days away from work or job transfer rates, and any serious, willful, or repeat OSHA violations. It also asks for the contractor's North American Industry Classification System code, who administers its safety program, and insurance experience modification rates for the past three years. Contractors are required to submit this completed form along with supporting documentation like OSHA 300 and 300A forms when proposing for the medical gas system upgrade project under solicitation number 36C24123R0150 being offered by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 1.
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PRE-AWARD CONTRACTOR EVALUATION FORM
COMPLETE & SUBMIT WITH PROPOSAL
(FROM CFM WEBSITE)
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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 explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)
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. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program? __________________________________
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________
File details come from the government source that posted it. Updated .