S02 Pre-Award Contractor Evaluation Form.docx
DOCX document 18 KB Posted
- Solicitation number
- 36C24122B0011
About this file
This document contains a pre-award contractor evaluation form and details of a federal solicitation for roof replacement projects. The pre-award form requests information from prospective contractors including OSHA recordable incident rates for the past three years, primary NAICS code, safety program administrator, and experience modification rates. Contractors must attach copies of their OSHA 300 and 300A forms as well as an explanation for any serious, willful, or repeat violations from OSHA in the last three years. Three such violations would disqualify the contractor.
The related federal solicitation is for roof replacement projects at two buildings on the West Haven VA Medical Center campus. The solicitation is identified as number 36C24122B0011 and includes replacement of the morgue and building 35A roofs. The solicitation documents are in Standard Form 1442 and Invitation for Bid format. The soliciting agency is listed as the Department of Veterans Affairs Veterans Health Administration 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 .