EXHIBIT B CONTRACTOR EVALUATION FORM 1.docx
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- Solicitation number
- 36C25624R0105
About this file
This document is an Exhibit B Contractor Evaluation Form for a construction safety contract opportunity. The form gathers information on the contractor's safety performance, including OSHA 300 metrics, safety and health program administration, and the contractor's current Insurance Experience Modification Rate (EMR). Contractors must provide this information, along with copies of OSHA 300 and 300a forms, as part of the solicitation requirements. If the EMR is greater than 1.0, the contractor must also provide a written explanation from the insurance carrier describing the reasons for the EMR and the anticipated date it may be reduced to 1.0 or below. This information will be used to evaluate the contractor's safety record as part of the selection process for the federal contract opportunity to Renovate Stairwells 586-23-104 for the Department of Veterans Affairs.
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FOR OFFICIAL USE ONLY
Exhibit B 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 .