Pre-Award Contractor Eval Safety Form - Replace Laundry HVAC Resolicit.docx
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- Attached to
- Z1DZ--402-22-755 Replace Laundry HVAC
- Solicitation number
- 36C24124R0104
About this file
The document is a Pre-Award Contractor Evaluation Safety Form for a VA contract to replace HVAC systems in laundry rooms at the Togus Campus VA Medical Center in Maine. The solicitation (36C24124R0104) requires contractors to provide labor, materials, and services for HVAC system repair and replacement, with a tiered evaluation process that provides preference to Service-Disabled Veteran-Owned Small Businesses (SDVOSBs), followed by Veteran-Owned Small Businesses (VOSBs), Women-Owned Small Businesses (WOSBs), other small businesses, and lastly large businesses.
The safety form requires potential contractors to submit detailed safety documentation, including OSHA 300 forms documenting man-hours, workplace injury cases, and Days Away, Restricted, or Transferred (DART) rates for 2021-2023. Contractors are disqualified if they have four serious violations, one repeat violation, or one willful violation, and must have an Experience Modification Rate (EMR) of 1.0 or less. Contractors must provide their NAICS code, identify who administers their safety program, and attach relevant OSHA documentation with their proposal.
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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 .