EXHIBIT B CONTRACTOR EVALUATION FORM.docx
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- Solicitation number
- 36C25622R0076
About this file
This document contains a contractor evaluation form and details of a related federal contract opportunity. The contractor evaluation form requests safety-related information from contractors such as man-hours, OSHA recordable incidents, violation rates, and safety program details. Contractors must also provide OSHA forms and explanation for any violations. The related federal contract opportunity is issued by the Department of Veterans Affairs for project 564-22-107 to replace fan coil units at a Veterans Health Administration facility. Offerors are requested to submit responses by the specified solicitation closing date.
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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 |
| 2019 |
| 2020 |
| 2021 |
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.
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