EXHIBIT B CONTRACTOR EVALUATION FORM.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C25624R0045
About this file
This document is an Exhibit B Contractor Evaluation Form that is part of a federal contract opportunity. The form requires the contractor to provide information about their safety record, including the number of man-hours, OSHA incidents, violations, and their current Insurance Experience Modification Rate (EMR). The contractor is asked to attach copies of their OSHA 300 and 300a forms, and if their EMR is greater than 1.0, provide a written explanation from their insurance carrier. The related federal contract opportunity is for a project called "Y1NZ--598-22-102 | Fisher House Utilities Site Prep - JLM" with Solicitation Number 36C25624R0045, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The solicitation is for site preparation work related to the Fisher House utilities.
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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 .