4-G. Bonfire Contractor Safety Assessment Form.pdf
PDF 87 KB Posted
- Attached to
- Siphon Cleaning Services
- Solicitation number
- FY26-RFP-11
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
The document is a Contractor Safety Assessment Form issued by Charlotte Water, designed to evaluate the safety credentials and documentation of potential contractors. The form requires companies to provide comprehensive safety program information, including details about their written safety and health program, employee training status, OSHA annual summaries, and any past OSHA citations or violations. Contractors must also disclose their NAICS code and report their company's and industry's DART (Days Away, Restricted, or Transferred) incidence rates for the past three years.
The form additionally mandates submission of various insurance documentation, specifically requiring copies of workers' compensation, commercial general liability, automobile liability, and professional liability insurance certificates. Companies with 10 or fewer employees have some documentation exemptions. The form is structured to ensure that contractors working with Charlotte Water meet rigorous safety standards and maintain appropriate insurance coverage, with spaces provided for company information, safety representative contact details, and an authorized signature to validate the submitted information.
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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:
http://www.bls.gov/
| 1. Organization Information: |
| Company Name: |
| Phone #: |
| On-Site Representative: |
| Email: |
| Phone #: |
| Safety Representative: |
| Email: |
| 2. Safety Program Documentation: |
| N/A |
| Yes |
| 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. |
| Rate |
| Year |
| 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? |
| N/A |
| Yes |
| 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) |
File details come from the government source that posted it. Updated .