2-G. Contractor Safety Assessment Form.pdf

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:

http://www.bls.gov/