7-H. Contractor Safety Assessment Form.pdf
PDF 121 KB Posted
- Solicitation number
- FY26-ITB-08
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form for the McDowell Creek Water Resource Reclamation Facility (WRRF) Primary Clarifier No. 4 Equipment project in North Carolina. The form requires bidding contractors to submit comprehensive safety documentation and organizational information as part of their proposal. Contractors must provide company contact information for both an on-site representative and a designated safety representative, along with evidence of a written safety and health program (unless the company has 10 or fewer employees). Additionally, contractors are required to submit OSHA annual summary forms (Form 300A) for the past three years, documentation of any OSHA citations or violations from the same period, and their company's NAICS code for industry classification purposes.
The assessment form also mandates submission of multiple insurance certificates of insurance, including workers' compensation, commercial general liability, and automobile liability coverage, with professional liability insurance (errors and omissions) required if applicable to the project scope. Contractors must provide their DART (Days Away, Restricted, or Transferred) incidence rates for the past three years and identify the corresponding industry DART rates for comparison purposes. All documentation must be signed and dated by an authorized company representative, with the specific insurance requirements determined by the scope of the clarifier equipment contract.
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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 .