S02 PRE-AWARD CONTRACTOR EVALUATION FORM (1).pdf
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- Attached to
- Z1DA--NextGen WiFi Upgrades Federal contract opportunity
- Solicitation number
- 36C24125B0001
About this file
This document is a Pre-Award Contractor Evaluation Form that the company must complete and submit with their proposal for the federal contract opportunity.
The key details are:
- The company must provide their OSHA 300 form data for the past 3 years, including number of man hours, days away/restricted/transferred cases, and DART rate. They must also report any OSHA violations in the past 3 years.
- The company must provide their 6-digit NAICS code and identify who administers their safety and health program.
- The company must report their Insurance Experience Modification Rate (EMR) for the past 3 years. This information will be used to evaluate the company's safety record and qualifications prior to award of the federal contract opportunity.
The related federal contract opportunity is for a Firm Fixed Price Construction contract to update the WiFi system at the Bedford VAMC campus. The magnitude of construction is between $25,000-$100,000 and the contract is subject to Wage Rate Requirements. It is a Service-Disabled Veteran Owned Small Business set-aside. Bids are due by 11:00 AM EST on December 18, 2024, with a public bid opening at that time. A site visit is scheduled for December 3, 2024.
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Text version
PRE-AWARD CONTRACTOR EVALUATION FORM
COMPLETE & SUBMIT WITH PROPOSAL
(FROM CFM WEBSITE)
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
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: _____________
File details come from the government source that posted it. Updated .