S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
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- Solicitation number
- 36C24122B0010
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This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for steam trap replacements. The evaluation form requests contractors to provide safety records including OSHA forms from the past three years, insurance experience modification rates, and information on who administers their safety and health program. The related federal contract opportunity is solicitation number 36C24122B0010 for steam trap replacements at VA medical centers in West Haven and Newington, Connecticut. The solicitation is open to all US firms and is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 1. Responses are due by the date specified in the IFB, and the agency intends to make award based on low price technically acceptable offers.
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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: _____________ http://www.osha.gov/pls/publications/publication.html
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