S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
PDF 82 KB Posted
- Attached to
- Z2DA--631-22-001 Abate Asbestos Q1 2022
- Solicitation number
- 36C24122B0004
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for asbestos abatement services. The pre-award evaluation form requests information from prospective contractors including OSHA injury rates, NAICS code, safety program administration, and insurance experience modification rates. Contractors must attach documentation of OSHA forms and explain any serious, willful, or repeat violations. The related federal contract opportunity is for asbestos abatement services in the first quarter of 2022, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 1. The solicitation number and a brief description of an attached invitation for bid are provided.
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| S06_IMG_0588.jpg | JPG image | |
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| S06_Wage Determination_MA20220003_06032022.docx | DOCX document | |
| S06_IMG_0587.jpg | JPG image | |
| 36C24122B0004 0001.docx | DOCX document | |
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| S02 Specification 631-22-001.pdf | ||
| 36C24122B0004_1.docx | DOCX document | |
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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 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 .