EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
DOCX document 28 KB Posted
- Solicitation number
- 36C25621R0112
About this file
This document contains an evaluation form for contractor safety on a federal construction project. The form requests safety-related information from bidders, including total man-hours and OSHA recordable incident rates for the past three years. Bidders must provide copies of their OSHA 300 and 300A forms, identify their safety program administrator, and disclose their current insurance experience modification rate with explanation if over 1.0.
The related federal contract opportunity is to replace the roof and HVAC system for Building 3 at the Alexandria VA Health Care System in Pineville, Louisiana, with a construction cost between $5,000,000 and $10,000,000. The solicitation will be issued on June 15, 2021 as a 100% set-aside for verified Service-Disabled Veteran-Owned Small Businesses. Interested SDVOSBs must meet limitations on subcontracting and be registered in the Vendor Information Pages and System for Award Management databases. The contracting office points of contact are provided.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25621R0112 0001.docx | DOCX document | |
| BLDG 3 Site Visit Information.pdf | ||
| WDLA202110051 04302021.txt | TXT text file | |
| 36C25621R0112.docx | DOCX document | |
| EXHIBIT F REQUEST FOR INFORMATION FORM.docx | DOCX document | |
| Vol 2-Specs.pdf | ||
| ACM and LeadReports.pdf | ||
| Drawings volume 2.pdf | ||
| Drawings Volume 1.pdf | ||
| EXHIBIT B PAST AND PRESENT PERFORMANCE QUESTIONNAIRE.docx | DOCX document | |
| EXHIBIT E SURETY FORM.docx | DOCX document | |
| J_A 502-19-102 (BC Signed) v1_Redacted.pdf | ||
| EXHIBIT A PERFORMANCE RELEVANCY SURVEY.docx | DOCX document | |
| EXHIBIT G RETURNABLES.docx | DOCX document | |
| Vendor Request Form.xlsx | XLSX spreadsheet | |
| Vol 1-Specs v2.pdf | ||
| Project Risk Assessment Replace Roof and HVAC building 3.pdf | ||
| EXHIBIT C SUBCONTRACTOR INFORMATION AND CONSENT.docx | DOCX document | |
| VA10091 FMS Vendor Request Form EFT.pdf | ||
| SOW-04052021.docx | DOCX document |
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 502-19-102 Replace BLDG 3 Roof & HVAC 36C25621R0112
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 .