EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
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- Attached to
- Z2DA--520-21-1-7032-0001 - Project 520-22-125 Replace Nurse Call System (VA-21-00015374)
- Solicitation number
- 36C25621R0053
About this file
This document contains an evaluation form for contractor safety on a federal construction project. The form requests safety data from the last three years including total man hours, OSHA recordable incidents, injury rates, and violations. It also asks who administers the company's safety program and current insurance experience modification rate.
The related federal contract opportunity is to replace the nurse call system at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi for $500,000 to $1,000,000. A 100% set-aside for Service-Disabled Veteran-Owned Small Businesses, the solicitation will be issued through full and open competition with a request for proposals. Proposals are due around March 1, 2021 with award intended within 30 days thereafter. The 120-day period of performance will commence with the notice to proceed. The NAICS code is 238210 and size standard is $16.5M. At least 15% of labor costs must be self-performed for general construction and 25% for specialty trades. Offerors must be verified as SDVOSBs in the Vendor Information Pages database.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 520-22-125 Replace Nurse Call System, Biloxi 36C25621R0053
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 .