EXHIBIT C CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C25621R0093
About this file
This document contains a pre-solicitation notice and contractor evaluation form for a construction project. The Department of Veterans Affairs VISN 16 will solicit bids to create a new main entrance at the John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas between $5-10 million. The NAICS code is 236220 and it is designated a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses. The projected posting date for the solicitation is May 5, 2021 on beta.SAM.gov. The contractor evaluation form requests safety-related documentation and insurance information from prospective bidders to assess their safety records and experience modification rates.
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Other files
| File | Type | Posted |
|---|---|---|
| Attch C Wage Determination AR20210027.txt | TXT text file | |
| EXHIBIT D - EMR Form.pdf | ||
| EXHIBIT B Past and Present Performance Questionnaire.pdf | ||
| Attch B Construction Drawings.pdf | ||
| 36C25621R0093.docx | DOCX document | |
| Attch A Construction Specifications.pdf | ||
| EXHIBIT A PERFORMANCE RELEVANCY SURVEY.docx | DOCX document |
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FOR OFFICIAL USE ONLY
Exhibit C Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
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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