11-I. Contractor Safety Assessment Form.pdf
PDF 121 KB Posted
- Attached to
- Mallard Creek WRRF NPW Filter System
- Solicitation number
- FY26-ITB-10
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form used by Charlotte Water in North Carolina to evaluate the safety qualifications and compliance of bidders for the Mallard Creek Water Resource Recovery Facility (WRRF) NPW Filter System project. The form requires contractors to provide comprehensive documentation regarding their safety programs, employee training status, and historical safety performance metrics. Specifically, bidders must submit their written safety and health program (if applicable), evidence of current employee safety training, OSHA Form 300A annual summaries for the past three years, documentation of any OSHA citations or violations from the previous three years, their company's North American Industrial Classification System (NAICS) code, and their Days Away, Restricted, or Transferred (DART) incidence rate for the past three years compared to industry benchmarks.
In addition to safety documentation, the form requires contractors to provide proof of adequate insurance coverage, including workers' compensation certificates, commercial general liability certificates, automobile liability certificates, and professional liability certificates for errors and omissions where applicable. The specific insurance requirements are contingent upon the scope of the project and contract requirements. All submissions must be completed, signed, and dated by an authorized company representative, including printed name and contact information for both the on-site representative and safety representative. This assessment tool establishes a baseline safety standard for contractor selection and ensures compliance with occupational health and safety requirements for the filter system installation at the municipal water facility.
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Text version
Contractor Safety Assessment Form
1. Organization Information:
Company Name:
On-Site Representative: Phone #:
Email:
Safety Representative: Phone #:
Email:
2. Safety Program Documentation:
Yes N/A
Does your company have a written safety and health program that is available upon request?* Are your employees current on all applicable safety-related training?
Provide copies of your OSHA annual summary (Form 300A) for the past 3 years.^ Provide copies of any OSHA citations or violations for the past 3 years.
Provide your company’s NAICS** code.
Year Rate
• What is your company’s DART incidence rate for the past 3 years?
• What is your industry’s DART incidence rate for the past 3 years?
* A written safety program is not required for companies with 10 or less employees.
^If your company is/was exempt from filing Form 300A for any given year, provide an explanation detailing such exemption (e.g., less than 10 employees).
** NAICS – North American Industrial Classification System – If you need assistance with this information, please refer to the Bureau of Labor Statistics (BLS) website at www.bls.gov or contact a safety consultant.
3. Insurance-Coverage Documentation:
Yes N/A
A copy of your workers’ compensation certificate of insurance A copy of your commercial general liability certificate of Insurance A copy of your automobile liability certificate of insurance A copy of your professional liability certificate of insurance for errors and omissions (if applicable)
Based on the scope of the project/contract, insurance documentation must be submitted.
4. Sign and date the form:
Authorized Signature: Date:
Print Name:
File details come from the government source that posted it. Updated .