EXHIBIT C- Contractor Evaluation Form Contractor Safety.pdf
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- Solicitation number
- 36C25626R0018
About this file
This is a Contractor Evaluation Form for construction safety assessment associated with the Site Prep IR Upgrade project (Project No. 586-25-101, Contract No. 36C25626R0018). The form is designated for official use only and contains source selection sensitive information.
The evaluation form requires contractors to provide comprehensive safety performance data across three years (2023, 2024, and 2025), including total man hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity, and calculated DART rates (Days Away, Restricted, or Transferred rates). Contractors must also disclose the number of serious, willful, or repeat OSHA violations incurred within the past three years with supporting explanations, and submit copies of OSHA 300 and 300a Forms. Additionally, contractors must identify the individual responsible for administering their Safety and Health Program and provide their current Insurance Experience Modification Rate (EMR) obtained directly from their insurance carrier on carrier letterhead. If the EMR exceeds 1.0, contractors must attach a written explanation from the insurance carrier describing the reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104
Project No.586-25-101; SITE PREP IR UPGRADE 36C25626R0018
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 2023 2024 2025 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
File details come from the government source that posted it. Updated .