S02 PRE-AWARD CONTRACTOR EVALUATION FORM.docx
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- Attached to
- Z1DA--608-23-133, Third Floor Lab Construction Federal contract opportunity
- Solicitation number
- 36C24124B0052
About this file
This document is a Pre-Award Contractor Evaluation Form that must be completed and submitted with a proposal for federal contract opportunity 36C24124B0052, which is for the Third Floor Lab Construction at the Manchester, VAMC.
The form requires the contractor to provide information on their OSHA 300 Forms, including the number of man hours, days away/restricted/transferred cases, and DART rate for 2020-2022. The contractor must also list any serious, willful, or repeat OSHA violations from the last 3 years and attach the OSHA 300 and 300a forms. Additionally, the contractor must provide their 6-digit NAICS code, who administers their safety program, and their Insurance Experience Modification Rate (EMR) for the past 3 years. This information is used to evaluate the contractor's safety record and qualifications prior to award.
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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 .