EXHIBIT D Safety Form.pdf
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- Attached to
- Modernize 6N Inpatient Restrooms (Swing for 3N)
- Solicitation number
- 36C25626R0108
About this file
This is a Contractor Evaluation Form for Construction Safety, which is Exhibit D of a federal solicitation for the modernization of 6N Inpatient Restrooms (with swing coverage for 3N) under contract number 36C25626R0108, Project No. 667-27-130.
The form requires contractors to submit detailed safety performance data covering three years (2024, 2025, 2026), including total man hours for jobsite and office work, the number of cases involving days away from work or restricted activity, the Days Away, Restricted, or Transferred (DART) rate calculated using OSHA's standard formula, and the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations cited. Contractors must attach copies of their OSHA 300 and 300a Forms as supporting documentation. Additionally, the form requests identification of the individual administering the company's Safety and Health Program and requires submission of the company's current Insurance Experience Modification Rate (EMR) obtained from the offeror's insurance carrier on carrier letterhead. If the EMR exceeds 1.0, contractors must attach a written explanation from the insurance carrier detailing the reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below. This template is designated for official use only and serves as the evaluation criterion for assessing contractor safety performance during the source selection process.
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Text version
FOR OFFICIAL USE ONLY
Modernize 6N Inpatient Restrooms (Swing for 3N)
Source Selection Information - See FAR 2.101 and 3.104 36C25626R0108 | Project No. 667-27-130
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 2024 2025 2026 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.
http://www.osha.gov/pls/publications/publication.html
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