EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
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- Solicitation number
- 36C25621R0040
About this file
This document contains a contractor evaluation form and details of a federal contract opportunity for generator controls upgrade work. The evaluation form requests safety-related information from contractors including OSHA forms, injury rates, violations, insurance rates, and safety program administration. The federal contract opportunity is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses issued by the Department of Veterans Affairs. The solicitation seeks generator controls upgrade work at a Gulf Coast Veterans Health Care facility with a performance period of 120 days from notice to proceed. The estimated value is between $500,000 to $1 million. The response deadline is approximately 30 days from issuance with award 30 days after. Offerors must be registered in relevant federal databases and meet limitations on subcontracting for the work.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 520-22-101 Generator Controls Upgrade, Biloxi 36C25621R0040
Exhibit D 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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