EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
DOCX document 27 KB Posted
- Attached to
- Z2NB--INSTALL SOFTWATER EQUIPMENT
- Solicitation number
- 36C25621R0022
About this file
This document contains a contractor evaluation form for construction safety related to a federal contract opportunity to install softwater equipment. The form requests safety-related information over the past three years including man hours, OSHA recordable incidents, DART rates, violations, and insurance experience modification rates. Contractors must submit OSHA 300 forms and insurance documentation. The related federal contract opportunity is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses to replace an HVAC system at a VA health care facility located in Pineville, Louisiana. The performance period is 365 days with proposals due around June 2020 and contract award around 30 days later. The estimated value is between $5-10 million.
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| 36C25621R0022 0001.docx | DOCX document | |
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 629-17-109 Install Softwater Equipment 36C25621R0022
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 .