EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
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- Solicitation number
- 36C25621R0055
About this file
This document contains a contractor evaluation form and details of a federal contract opportunity for upgrade work. The evaluation form requests safety-related information and documents from offerors, including OSHA forms and insurance rates.
The federal contract opportunity is to upgrade emergency electrical systems at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi. The 100% set-aside contract for Service-Disabled Veteran-Owned Small Businesses has an anticipated value between $500,000 and $1 million. The solicitation will be issued through Requests for Proposal with proposals due around February 25, 2021 and contract award approximately 30 days later. The 120-day period of performance will commence with the notice to proceed. NAICS code 238210 applies with a small business size standard of $16.5 million. Offerors must meet limitations on subcontracting and eligibility requirements for SDVOSBs as outlined.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 520-22-108 Upgrade Emergency Electrical Systems, Biloxi 36C25621R0055
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 .