EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY.docx
DOCX document 30 KB Posted
- Attached to
- Z1DA--Installation of Additional Environmental Monitors Federal contract opportunity
- Solicitation number
- 36C25621R0131
About this file
This document contains a contractor evaluation form for construction safety and related federal contract opportunity for the installation of additional environmental monitors. Key details include:
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The contractor evaluation form requests safety-related information such as man hours, OSHA recordable incidents, injury rates, violations, and insurance experience modification rates. Supporting documents including OSHA forms and an explanation for rates over 1.0 are required.
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The federal contract opportunity is to install additional environmental monitors at the Southeast Louisiana Veterans Health Care System in New Orleans. The estimated value is between $500,000 and $1,000,000. The NAICS code is 238220 and size standard is $16.5 million. The solicitation will be issued on June 4, 2021 as a 100% small business set-aside for service-disabled veteran-owned small businesses. Offerors must be registered and verified in the Vendor Information Pages and System for Award Management databases to be considered for award.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 629-21-102 Installation of Additional Environmental Controls 36C25621R0131
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 .