Pre-Award Contractor Evaluation Form.docx
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- Solicitation number
- 36C24123B0001
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for metal coping and roof repair/replacement projects at a VA medical campus in Newington, Connecticut. The pre-award evaluation form requests company information including OSHA recordable incident rates for the past three years, North American Industry Classification System code, safety program administrator, and experience modification rates. Bidders are instructed to attach OSHA forms and other documentation. The related federal contract opportunity is solicited by the Department of Veterans Affairs and seeks bids to perform metal coping and roof repair/replacement at the Newington VA campus, as described in the attached SF-1442 and IFB. Relevant details include the solicitation and project numbers, location, and involvement of the Veterans Health Administration and Veterans Integrated Service Network 1.
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PRE-AWARD CONTRACTOR EVALUATION FORM
(COMPLETE AND SUBMIT WITH PROPOSAL)
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ E-mail: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing the OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
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 Form).
Days away, restricted, or transferred rate (Number of days away, restricted, or transferred cases x 200,000 / Number of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last three (3) years. Attach explanation for any violations. (Three 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 the six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________ |
| 3. | Who administers the company’s Safety and Health Program? __________________________________ |
| 4. | Company’s Insurance Experience Modification Rate (EMR) for the past three (3) years: _____________ |
File details come from the government source that posted it. Updated .