3-I. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- Creative Services for Storm Water Services
- Solicitation number
- FY27-RFP-02
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form associated with Charlotte-Mecklenburg Storm Water Services (CMSWS) in North Carolina, which is soliciting creative services for storm water education and outreach campaigns. The form is designed to evaluate contractor safety compliance and documentation prior to project assignment. Contractors must provide comprehensive safety program documentation, including written safety and health policies, proof of current employee safety training, OSHA Form 300A summaries for the past three years, and any OSHA citations or violations from the same period. Contractors must also supply their NAICS code and their company's DART (Days Away, Restricted, or Transferred) incidence rate for the past three years, along with their industry's comparable DART rate for benchmarking purposes.
The assessment form requires documentation of insurance coverage including workers' compensation, commercial general liability, automobile liability, and professional liability certificates for errors and omissions where applicable. All required documentation must be submitted based on the scope of the project or contract. The form mandates that an authorized company representative sign and date the submission, providing contact information for both an on-site representative and a dedicated safety representative. A written safety program is not required for companies with ten or fewer employees, and companies exempt from filing OSHA Form 300A must provide written explanation of their exemption status.
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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 .