EXHIBIT A CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.pdf
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- Solicitation number
- 36C25621R0059
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This document contains an evaluation form for contractor safety and a solicitation for a design-build project to modify HVAC systems at a Veterans Affairs medical center to allow for switching between normal recirculation and 100% outside air in response to the COVID-19 pandemic. The evaluation form requests safety-related information and documents from offerors for the past three years, including OSHA injury logs, experience modification rates, and details of any serious violations. The solicitation is a two-phase acquisition where qualified Service-Disabled Veteran-Owned Small Businesses may submit proposals for Phase I, with selected Phase II offerors invited to attend an on-site visit and submit final proposals. The contractor will be responsible for designing and constructing modifications to the inpatient building's HVAC system at the Southeast Louisiana Veterans Health Care System to enable toggling between normal and pandemic operating modes.
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Exhibit A Contractor Evaluation Form
Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2017 2018 2019
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 will lower technical rating of offeror significantly.)
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):___________________ http://www.osha.gov/pls/publications/publication.html
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