S02 PRE-AWARD CONTRACTOR EVALUATION FORM.pdf
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- Solicitation number
- 36C24123B0002
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This document contains a pre-award contractor evaluation form and information on a related federal contract opportunity for construction services. The pre-award evaluation form requests information from prospective contractors, including OSHA recordable incident rates for the past three years, NAICS code, safety program administration details, and insurance experience modification rates. Contractors must attach explanations for any serious, willful, or repeat OSHA violations, as well as copies of OSHA forms 300 and 300A. The related federal opportunity is a presolicitation notice from the Department of Veterans Affairs for construction services to build three floors for women's health at a Veterans Integrated Service Network location. The notice references an attached invitation for bid but does not provide further details on required scopes of work, response deadlines, or award timelines.
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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 2020 2021 2022 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 .