EXHIBIT F - Pre-Award Contractor Eval Safety Form.docx
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- Solicitation number
- 36C24123R0112
About this file
This document is a pre-award contractor evaluation form for a federal contract opportunity to perform water tank painting and repair services. The form requires contractors to provide safety information including OSHA 300 and 300a forms from the past three years, total man hours, number of injury cases, days away from work rates, and any serious, willful, or repeat OSHA violations. Contractors must also provide their six-digit NAICS code and insurance experience modification rates for the past three years. The related federal contract opportunity is solicitation number 36C24123R0112 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 1 to provide water tank painting and repair services.
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PRE-AWARD CONTRACTOR EVALUATION FORM
COMPLETE & SUBMIT WITH PROPOSAL
(FROM CFM WEBSITE)
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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 explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)
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. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program? __________________________________
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________
File details come from the government source that posted it. Updated .