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Exhibit D Safety Form

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A PDF document (80 KB) attached to Modernize 6N Inpatient Restrooms (Swing for 3N), from the Department of Veterans Affairs. Due Nov 20, 2026, 2:00 PM (UTC-6).

File name: EXHIBIT D Safety Form.pdf

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Modernize 6N Inpatient Restrooms (Swing for 3N)
Exhibit D
Contractor Evaluation Form
Construction Safety
1. Utilizing your OSHA 300 Forms, please complete the following information: Category

2024

2025

2026

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 explanations for any violations.
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.
The above EMR rate must be obtained from offeror’s insurance carrier and furnished on insurance carrier’s letterhead. If EMR is greater than 1.0, attach a written explanation of the EMR from insurance carrier on insurance carrier’s letterhead describing the reasons for the EMR and the anticipated date the EMR may be reduced to 1.0 or below.

Source Selection Information - See FAR 2.101 and 3.104

36C25626R0108 | Project No. 667-27-130

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