S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
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- Attached to
- Z2NZ--631-21-003 Upgrade Sanitary Sewer Phase 2
- Solicitation number
- 36C24122B0003
About this file
This document contains a pre-award contractor evaluation form for federal contractors to complete and submit with proposals. The form requests information on the contractor's OSHA 300 forms from 2019 to 2021 including man hours, cases involving days away from work or restricted activity, and days away/restricted/transferred rate. It also asks for details on any serious, willful, or repeat OSHA violations in the past three years. The contractor must provide its six-digit NAICS code and identify the person who administers its safety and health program. Insurance experience modification rates for the past three years are also solicited. Copies of the contractor's OSHA 300 and 300a forms must be attached.
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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 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).
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 .