EXHIBIT D CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY v2.docx
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- Attached to
- Z2NB-- Project 667-18-101 Correct Tunnel Discrepancies Federal contract opportunity
- Solicitation number
- 36C25621R0158
About this file
This document contains an evaluation form for contractor safety and a solicitation for corrective tunnel work at a VA medical center. The evaluation form requests contractors to provide OSHA 300 and 300A forms from the past three years along with explanations for any serious violations. It also asks for the contractor's current experience modification rate from their insurance carrier and who administers their safety and health program.
The solicitation is a 100% set-aside for service-disabled veteran-owned small businesses to correct tunnel discrepancies at the Overton Brooks VA Medical Center in Shreveport, Louisiana. The construction cost is estimated between $500,000 to $1,000,000, with a 200-day performance period after notice to proceed. The solicitation will be issued on July 15, 2021 via the SAM website, with proposals due around August 15, 2021. To be eligible, offerors must be verified as SDVOSBs through the VetBiz registry and registered in SAM by the time of proposal submission.
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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 .