Pre-Award Contractor Eval Safety Form - Replace Laundry HVAC Resolicit.docx
DOCX document 14 KB Posted
- Attached to
- Z1DZ--402-22-755 Replace Laundry HVAC
- Solicitation number
- 36C24124R0062
About this file
This document is a Pre-Award Contractor Evaluation Form that must be completed and submitted with a proposal for the federal contract opportunity to Replace Laundry HVAC at the VA Maine, Togus Campus.
The key details are:
- The contract is a 100% small business set-aside for the repair and replacement of the HVAC system in the laundry rooms.
- Offerors must provide their OSHA 300 form data for the past 3 years, including man-hours, DART rate, and any OSHA violations.
- Offerors must provide their 6-digit NAICS code, information on who administers their safety program, and their past 3-year insurance Experience Modification Rate (EMR).
- Proposals must be submitted via email in PDF, DOCX, or DOC format by June 6, 2024 at 5:00 PM EST. No ZIP files will be accepted.
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Text version
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 |
| 2021 |
| 2022 |
| 2023 |
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 .