EXHIBIT B CONTRACTOR EVALUATION FORM.docx
DOCX document 28 KB Posted
- Solicitation number
- 36C25623R0004
About this file
This document contains an exhibit for evaluating contractor safety performance on federal construction projects. The evaluation form requests contractors to provide health and safety metrics including man-hours worked, OSHA recordable injuries, days away from work cases, and serious safety violations over the past three years. Contractors must also submit current OSHA forms 300 and 300A and identify their safety program administrator as well as current insurance experience modification rate and explanations for any rates over 1.0. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs for exterior weatherproofing work at the Jackson VA Medical Center.
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Other files
| File | Type | Posted |
|---|---|---|
| Project Addendum 2 page.pdf | ||
| AMENDMENT 0002 - 36C25623R0004 0002.docx | DOCX document | |
| SITE VISIT SIGN IN SHEET.pdf | ||
| AMENDMENT 0001 - 36C25623R0004 0001.docx | DOCX document | |
| PRE-BID RFIs - COMPLETE.pdf | ||
| WAGE DETERMINATION MS20220051 02-25-2022.txt | TXT text file | |
| Past and Present Performance Questionnaire.docx | DOCX document | |
| SOLICITATION 36C25623R0004_1.docx | DOCX document | |
| Binder1 Specifications.pdf | ||
| Scope of work 586-20-110.pdf |
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Text version
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.
File details come from the government source that posted it. Updated .