Exhibit D - Contractor Evaluation Form Construction Safety.docx
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- Solicitation number
- 36C25621R0172
About this file
This document contains a contractor evaluation form and details of a federal contract opportunity for construction services. The contractor evaluation form requests safety-related information and documents from offerors, including OSHA 300 forms from the past three years, details on their safety program administration, and current insurance experience modification rate.
The related federal contract opportunity is to construct a surface level parking lot in New Orleans for the Southeast Louisiana Veterans Health Care System. Offerors must be verified as a Service-Disabled Veteran-Owned Small Business. The solicitation number is provided, with an estimated construction cost between $1 million to $2 million. The performance period is 180 days after notice to proceed. The opportunity is 100% set aside for SDVOSBs, with limitations on subcontracting workshare requirements. The solicitation will be issued on September 24th with proposals due around October 26th and award by November 25th. Interested parties should monitor the beta.SAM.gov website for the full RFP and any amendments.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 629-18-107 Construct Surface Level Parking Lot, New Orleans 36C25621R0172
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.
File details come from the government source that posted it. Updated .