S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
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- Attached to
- Z2QA--631-22-002 Exterior Stair Improvement
- Solicitation number
- 36C24122B0006
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for exterior stair improvement work. The evaluation form requests safety and health information from bidding contractors, including OSHA recordable incident rates for the past three years, primary NAICS code, safety program administrator, and experience modification rates. Contractors must also attach explanations for any serious, willful, or repeat OSHA violations received in the past three years, with four or more violations disqualifying the bidder. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs for exterior stair improvement work at VISN 1 facilities. The solicitation number, title, opportunity type, description, and contracting agency are provided.
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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 .