EXHIBIT A CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY v2.docx
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- Solicitation number
- 36C25623R0120
About this file
This document is a contractor evaluation form for construction safety used by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form requests health and safety information from contractors including OSHA 300 and 300a forms from the previous three years detailing man hours worked, days away from work, injury rates, and any serious violations. It also asks for the name of the company's safety program administrator and current insurance experience modification rate along with an explanation if the rate is over 1.0. The related federal contract opportunity is a solicitation for amendment 0002 to perform painting and repair work at the John L. McClellan Memorial Hospital, with the solicitation number 36C25623R0120.
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FOR OFFICIAL USE ONLY
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 |
| 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 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 .