SAFETY RECORD QUESTIONNAIRE

PART A – SAFETY RECORD QUESTIONNAIRE FOR PRIME CONTRACTORS

(Part A must be submitted by prime contractor with its bid)

Pursuant to Harris County’s Safety Record Policy, this certification must be submitted in conjunction with this bid, as the project for which your company is bidding (1) for construction, rehabilitation, expansion, reconstruction, or maintenance work; (2) have a total contract value of at least $500,000 and, for subcontracts, a contract value of at least $50,000; (3) and are not exempted from the Safety Record Policy.

If every question on the certification is not marked “True,” or a response to a question in the Safety Record Questionnaire is found to be false, the bid will be deemed nonresponsive.

This determination will disqualify your company from only this bid—your company is not prohibited from bidding on other County projects.

CERTIFICATION ONE

The Contractor, or the firm, corporation, partnership, or institution represented by the Contractor, or anyone acting for such firm, corporation, partnership or institution, has not been listed on OSHA’s Severe Violator Enforcement Program (SVEP) Log at any time within the three (3) years preceding the date of this certification.

TRUE_____ FALSE_____

CERTIFICATION TWO

The Contractor, or the firm, corporation, partnership, or institution represented by the Contractor, has not been sanctioned with an OSHA Citation and Notification of Penalty classified as one of the following types (if the OSHA Citation is contested8 then its classification is based on the Settlement with OSHA or OSHA Final Order) within the twenty-four (24) months preceding9 the date of this certification:

8 If an OSHA Citation is contested, no sanctions under this policy apply until it is resolved. During that time, the bidder may truthfully state it has not been sanctioned under the certification language.

The bidder must notify Harris County within ten (10) business days of the OSHA decision and provide documentation of the outcome. Harris County is not obligated to award the bid, regardless of the result.

9 The Issuance Date of the Citation and Notification of Penalty is the relevant date when calculating the twenty-four (24) months preceding.

(1)“Serious” with a Gravity10 finding of “High” (2) “Posting Requirements” with a Gravity finding of “High”11.

Disclosure: Do you currently have any open/contested violations that fall under this certification?

YES_____ NO_____

CERTIFICATION THREE

The Contractor/Subcontractor has not been sanctioned with an OSHA Citation and Notification of Penalty classified as one of the following types (if the OSHA Citation is contested12, then its classification is based on the Settlement with OSHA or OSHA Final Order) and within three (3) years preceding13 the date of this certification:(1)“Willful or Repeated”; (2) “Failure to Abate”; and/or , TRUE_____ FALSE_____

Disclosure: Do you currently have any open/contested violations that fall under this certification?

YES_____ NO___

CERTIFICATION FOUR

The Contractor, or the firm, corporation, partnership, or institution represented by the Contractor, (i.e., the company itself, not the company’s employees) within the ten (10)

10 “Gravity” is used in this policy as it is explained in the most recent OSHA Field Operations Manual, as determined by the relevant OSHA Information System (OIS) code. The Policy does not depend on the monetary amounts of the penalties assessed by OSHA in association with citations.

11 As noted in Section III, this policy does not limit, or impact in any way, the County’s ability to consider in the manner it deems appropriate any relevant factor specifically listed in any request for bids, proposals, or qualifications. Thus, for example, even though this policy does not deem as nonresponsive bidders with OSHA violation types that are not listed, or requires certain thresholds with regard to

“Serious” or “Posting Requirement” type of violations, the County may still consider any OSHA violation type, Severity finding, or Probability finding in the scoring of bids, proposals, or qualifications as specified in the bid, proposal, or qualification request documents.

12 If an OSHA Citation is contested, no sanctions under this policy apply until it is resolved. During that time, the bidder may truthfully state it has not been sanctioned under the certification language.

The bidder must notify Harris County within ten (10) business days of the OSHA decision and provide documentation of the outcome. Harris County is not obligated to award the bid, regardless of the result.

13 The Issuance Date of the Citation and Notification of Penalty is the relevant date when calculating the three (3) years preceding years preceding the date of this certification, has not been convicted of a criminal offense in connection with a workplace incident that resulted in serious bodily injury or death.

TRUE_____ FALSE_____

Disclosure: Do you currently have any pending court cases or litigation for violations that fall under this certification?

YES_______ NO______

CERTIFICATION FIVE

Contractor employees that will be doing manual work under a contract with the County or other work that directly impacts workplace safety has received the OSHA 10 certification, and managers that manage at least one employee that will be doing manual work on the project or other work that directly impacts workplace safety received the OSHA 30 certification, prior to entering the job site and before the commencement of construction.

TRUE_____ FALSE_____

CERTIFICATION SIX

Contractor employees are compensated for the cost of their OSHA 10 certification (workers) or OSHA 30 certification (managers) if they received such certification while employed by you. Contractor employees are also compensated at their normal hourly rate for the time workers and managers spend toward those certifications.

TRUE_____ FALSE_____

It is the sole responsibility and obligation of the Contractor to ensure that all Subcontractors performing any part of the work on this project disclose to the Contractor their safety records and meet the County’s requirements under the Safety Record Policy. The Contractor may fulfill this obligation by distributing the “Safety Record Questionnaire for Subcontractors” form included in this policy as Part B to all subcontractors and verifying to the County that the forms have been satisfactorily completed (i.e., every response is a “True”) and returned to the Contractor. All Safety Record Questionnaires are subject to the County’s review upon request.

Prime Contractor must maintain subcontractor certifications for every subcontractor it uses to perform work on the project throughout the life of the project. Prime Contractor must also collect completed questionnaires from all subcontractors at least 30 days prior to the commencement of work and attest that this will be completed.

PRIME CONTRACTOR SAFETY RECORD CERTIFICATION

Project Title:

Name:

Title:

Business or Entity Name:

Business or Entity Address:

County of Contracting Entity:

THE STATE OF TEXAS

COUNTY OF HARRIS

I, ________________________________, certify that:

1. I am the _____________________________(position) of ________________________ __ (“Contracting Entity”) and have the authority to execute this Certification on behalf of Contracting Entity.

2. The information provided in this Safety Record Questionnaire is true and correct.

3. I have made no willful misrepresentations, nor have I withheld information in my statements and answers to questions in this Safety Record Questionnaire.

4. I acknowledge and understand that the Contracting Entity will be disqualified from participating in this project if the Contracting Entity is unable to confirm as “True” each question in the Safety Record Questionnaire.

5. I will ensure that all subcontractors that will work on this project will have satisfactorily completed and submitted to the Contracting Entity their Safety Record Questionnaires by 30 days before work begins.

6. The Contracting Entity will provide access to all records, and take whatever steps necessary (e.g., obtain and disclose Gravity findings from OSHA with respect to an OSHA citation, waive any confidentiality (only to the extent necessary to comply with this policy), etc.) to substantiate the responses in the Safety Record Questionnaire.

7. I am aware that the information I have provided in this Safety Record Questionnaire will be investigated, with my full permission, and that any misrepresentations or omissions may cause my bid to be rejected or the County to pursue any of the remedies foun d in Section VIII of the Safety Record Policy.

Signature

Date

PART B – SAFETY RECORD QUESTIONNAIRE FOR SUBCONTRACTORS

(Part B must be submitted by all subcontractors and submitted to the Prime Contractor with their bids. Prime Contractor is NOT required to submit this Part B with their bid.)

Pursuant to Harris County’s Safety Record Policy, this certification must be submitted in conjunction with this bid, as the project for which your company is bidding (1) for construction, rehabilitation, expansion, reconstruction, or maintenance work; (2) have a total contract value of at least $500,000 and, for subcontracts, a contract value of at least $50,000; (3) and are not exempted from the Safety Record Policy.

If every question on the certification is not marked “True,” or a response to a question in the Safety Record Questionnaire is found to be false, the Prime Contractor will not be able to use your services under its contract with the County. This determinat ion will disqualify your company from only this bid—your company is not prohibited from bidding on other County projects.

CERTIFICATION ONE

The Subcontractor, or the firm, corporation, partnership, or institution represented by the Subcontractor, or anyone acting for such firm, corporation, partnership or institution, has not been listed on OSHA’s Severe Violator Enforcement Program (SVEP) Log at any time within the three (3) years preceding the date of this certification.

TRUE_____ FALSE_____

CERTIFICATION TWO

The Subcontractor, or the firm, corporation, partnership, or institution represented by the Contractor, has not been sanctioned with an OSHA Citation and Notification of Penalty classified as one of the following types (if the OSHA Citation is contested14 then its classification is based on the Settlement with OSHA or OSHA Final Order) within the twenty-four (24) months preceding15 the date of this certification:

(1)“Serious” with a Gravity16 finding of “High” (2) “Posting Requirements” with a Gravity finding of “High”17.

14 If an OSHA Citation is contested, no sanctions under this policy apply until it is resolved. During that time, the bidder may truthfully state it has not been sanctioned under the certification language. The bidder must notify Harris County within ten (10) business days of the OSHA decision and provide documentation of the outcome.

Harris County is not obligated to award the bid, regardless of the result.

15 The Issuance Date of the Citation and Notification of Penalty is the relevant date when calculating the twenty-four

(24) months preceding.

16 “Gravity” is used in this policy as it is explained in the most recent OSHA Field Operations Manual, as determined by the relevant OSHA Information System (OIS) code. The Policy does not depend on the monetary amounts of the penalties assessed by OSHA in a ssociation with citations.

17 As noted in Section III, this policy does not limit, or impact in any way, the County’s ability to consider in the

Disclosure: Do you currently have any open/contested violations that fall under this certification?

YES_____ NO_____

CERTIFICATION THREE

The Subcontractor has not been sanctioned with an OSHA Citation and Notification of Penalty classified as one of the following types (if the OSHA Citation is contested 18, then its classification is based on the Settlement with OSHA or OSHA Final Order) and within three

(3) years preceding19 the date of this certification:(1)“Willful or Repeated”; (2) “Failure to Abate”; and/or , TRUE_____ FALSE_____

Disclosure: Do you currently have any open/contested violations that fall under this certification?

YES___ NO___

CERTIFICATION FOUR

The Subcontractor, or the firm, corporation, partnership, or institution represented by the Subcontractor (i.e., the company itself, not the company’s employees), within the ten (10) years preceding the date of this certification, has not been convicted of a criminal o ense in connection with a workplace incident that resulted in serious bodily injury or death.

TRUE_____ FALSE_____

Disclosure: Do you currently have any pending court cases or litigation for violations that fall under this certification?

YES_____ NO_____

manner it deems appropriate any relevant factor specifically listed in any request for bids, proposals, or qualifications. Thus, for example, even though this policy does not deem as nonresponsive bidders with OSHA violation types that are not listed, or requires certain thresholds with regard to “Serious” or “Posting Requirement” type of violations, the County may still consider any OSHA violation type, Severity finding, or Probability finding in the scoring of bids, proposals, or qualifications as specified in the bid, proposal, or qualification request documents.

18 If an OSHA Citation is contested, no sanctions under this policy apply until it is resolved. During that time, the bidder may truthfully state it has not been sanctioned under the certification language. The bidder must notify Harris County within ten (10) business days of the OSHA decision and provide documentation of the outcome.

Harris County is not obligated to award the bid, regardless of the result.

19 The Issuance Date of the Citation and Notification of Penalty is the relevant date when calculating the three (3) years preceding

CERTIFICATION FIVE

Subcontractor employees that will be doing manual work under contract between the County and the Prime Contractor or other work that directly impacts workplace safety has received the OSHA 10 certification, and managers that manage at least one employee that will be doing manual work on the project or other work that directly impacts workplace safety has received the OSHA 30 certification, by the first day of work on the project (if you are hired as a subcontractor on the project).

TRUE_____ FALSE_____

CERTIFICATION SIX

Subcontractor employees are compensated for the cost of their OSHA 10 certification (workers) or OSHA 30 certification (managers) if they received such certification while employed by you. Subcontractor employees are also compensated at their normal hourly rate for the time workers and managers spend toward those certifications.

It is the sole responsibility and obligation of the Contractor to ensure that all Subcontractors performing any part of the work on this project disclose to the Contractor their safety records and meet the County’s requirements under the Safety Record Policy. The Contractor may fulfill this obligation by distributing the “Safety Record Questionnaire for Subcontractors” form included in this policy as Part B to all subcontractors and verifying to the County that the forms have been satisfactorily completed (i.e., every response is a “True”) and returned to the Contractor.

Subcontractors should submit the Safety Record Questionnaire to the Contractor as soon as they are able to. Contractor shall have until 30 days before the start of work on the project to obtain certifications from its Subcontractors.

All safety records are to be submitted by the prime contractor as instructed on the first page of this Safety Record Questionnaire, and all such records are subject to Harris County’s review upon request.

SUBCONTRACTOR SAFETY RECORD CERTIFICATION

Project Title:

Name:

Title:

Business or Entity Name:

Business or Entity Address:

County of Contracting Entity:

THE STATE OF TEXAS

COUNTY OF HARRIS

I, ________________________________, certify that:

1. I am the ____________________________(position) of _________________________ _ (“Subcontracting Entity”) and have the authority to execute this Certification on behalf of Subcontracting Entity.

2. The information provided in this Safety Record Questionnaire is true and correct.

3. I have made no willful misrepresentations, nor have I withheld information in my statements and answers to questions in this Safety Record Questionnaire.

4. I acknowledge and understand that the Subcontracting Entity will be disqualified from participating in this project if the Subcontracting Entity is unable to confirm as “True” each question in the Safety Record Questionnaire.

5. I will ensure that the prime contractor on the project will receive this Safety Record Questionnaire by 30 days before work begins.

6. Subcontracting Entity will provide access to all records, and take whatever steps necessary (e.g., obtain and disclose Gravity findings from OSHA with respect to an OSHA citation, waive any confidentiality (only to the extent necessary to comply with this policy), etc.) to demonstrate compliance with the requirements of this policy.

7. I am aware that the information I have provided in this Safety Record Questionnaire will be investigated, with my full permission, and that any misrepresentations or omissions may cause my bid to be rejected or the County to pursue any of the remedies foun d in Section VIII of the Safety Record Policy.

Signature

Date

Safety Record Questionnaire for Sub-Contractors (Part B)