EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY v2.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C25621R0127
About this file
This document contains an exhibit for evaluating contractor safety performance on construction projects for the Department of Veterans Affairs. It requests safety-related documentation and insurance information from offerors, including OSHA 300 and 300A forms from the previous three years, details on any serious violations, and an explanation if the offeror's experience modification rate is over 1.0.
The related federal contract opportunity is a solicitation to replace refrigerators and freezers at the Overton Brooks VA Medical Center in Shreveport, Louisiana. It will be issued as a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses. Offerors should download the full solicitation from SAM.gov for details on proposal submission, pre-proposal site visit, and contract award which is expected within 30 days of proposals receipt with a 180 day period of performance. Offerors must be verified in Vendor Information Pages and registered in SAM to be considered for award.
View the file
Other files
Show 40 more
Latest 50 of 72 listed here. See the rest on GovTribe.
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
FOR OFFICIAL USE ONLY
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 |
| 2017 |
| 2018 |
| 2019 |
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 .