EXHIBIT C CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.pdf
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- Solicitation number
- 36C25621R0154
About this file
This document provides details for an upcoming federal construction contract opportunity with the Department of Veterans Affairs. The solicitation will require a general contractor to renovate approximately 13,599 square feet of space at the Eugene J. Towbin Veterans Hospital in North Little Rock, Arkansas to upgrade domiciliary units. Key aspects of the pre-solicitation notice include that the project budget is between $5-10 million, responses are due by July 15, 2021, and the work must comply with required drawings, specifications, and statement of work while maintaining ongoing hospital operations. Interested service-disabled veteran-owned small businesses must be registered in the Vendor Information Pages and System for Award Management databases and meet set-aside limitations for subcontracting percentages.
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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.
http://www.osha.gov/pls/publications/publication.html
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