EXHIBIT D.docx
DOCX document 29 KB Posted
- Attached to
- Bldg. 55 Accessibility Ramp
- Solicitation number
- 667-24-255
About this file
This is a contractor evaluation form (Exhibit D) focused on construction safety requirements for a federal solicitation. The form is part of solicitation 667-24-255 for Building 55 Accessibility Ramp project managed by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16, designated as a Veteran-Owned Small Business (VOSB) set-aside opportunity.
The evaluation form requires contractors to provide comprehensive safety performance data including OSHA 300 Forms for years 2022-2024, detailing man hours worked, workplace injury cases, Days Away Restricted or Transferred (DART) rates, and any serious OSHA violations within the past three years with explanations. Contractors must identify who administers their Safety and Health Program and provide their current Insurance Experience Modification Rate (EMR) on insurance carrier letterhead. If the EMR exceeds 1.0, contractors must include a written explanation from their insurance carrier describing the reasons and anticipated timeline for reduction to 1.0 or below. The form requires attachment of official OSHA 300 and 300a Forms accessible through the OSHA publications website.
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Other files
| File | Type | Posted |
|---|---|---|
| EXHIBIT A.docx | DOCX document | |
| EXHIBIT C.docx | DOCX document | |
| S02 B55 Ramp-Existing Drawing.pdf | ||
| S02 SOW 10-03-2024.pdf | ||
| S02 Wage Determination 667-24-255 -01-03-2025.pdf | ||
| 36C25625R0125_1 08-06-2025.docx | DOCX document | |
| S02 2016-03-21 Utilities Drawing.pdf | ||
| EXHIBIT B.docx | DOCX document | |
| EXHIBIT F.docx | DOCX document | |
| EXHIBIT E.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. 667-24-255 Bldg. 55 Accessibility Ramp 36C25625R0002
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 |
| 2022 |
| 2023 |
| 2024 |
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 .