S02 EXHIBIT A CONTRACTOR EVALUATION FORM CONSTRUCTION SAFETY .docx
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- Attached to
- Z1DA--CFM: CORRECT MISCELLANEOUS HVAC ISSUES Federal contract opportunity
- Solicitation number
- 36C25620R0097
About this file
This document contains a contractor evaluation form for construction safety used by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form requests health and safety information from bidding contractors, including OSHA 300 and 300a forms from the past three years detailing man hours worked, days away from work, restricted activity cases, and any serious, willful, or repeat OSHA violations. Contractors must also provide their current insurance experience modification rate and identify who administers their safety and health program. The related federal contract opportunity is for miscellaneous HVAC corrective work with solicitation number 36C25620R0097 to be awarded by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.
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Text version
FOR OFFICIAL USE ONLY
36C25620R0097
Exhibit A Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2017 |
| 2018 |
| 2019 |
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 may disqualify 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. Who administers your company’s Safety and Health Program?
3. Company’s current Insurance Experience Modification Rate (EMR):____________________________
File details come from the government source that posted it. Updated .