S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
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- Solicitation number
- 36C24122B0009
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This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for renovating the HVAC system and roof of a building at a Veterans Affairs medical center. The pre-award evaluation form requests information from prospective contractors such as OSHA recordable incident rates for the past three years, NAICS code, safety program administration details, and insurance modification rates. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs to renovate the HVAC system and roof of building 6 at the Veterans Integrated Service Network 1 medical center. No further specifics are provided on response dates, award dates, pricing terms, or other contractual details.
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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 .