8-H. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- On-Call Concrete Maintenance and Repair Services
- Solicitation number
- FY26-RFP-21
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form required by Charlotte Water in North Carolina for on-call concrete maintenance and repair services. The form establishes safety and compliance documentation requirements that prospective contractors must fulfill to qualify for the contract opportunity. Contractors must provide organizational information including company name, on-site representative details, and designated safety representative contact information. The assessment encompasses a comprehensive safety program evaluation requiring submission of written safety and health program documentation, proof of current employee safety training, OSHA Form 300A annual summaries for the past three years, and any OSHA citations or violations from the same period. Additionally, contractors must submit their North American Industrial Classification System (NAICS) code and provide their company's Days Away, Restricted, or Transferred (DART) incidence rates for the past three years along with their industry's corresponding DART rates for comparison purposes.
The insurance documentation section mandates submission of certificates of insurance covering workers' compensation, commercial general liability, and automobile liability coverage. Professional liability insurance for errors and omissions must also be provided if applicable to the scope of the project. The form requires authorization by an authorized company representative through signature and date, with printed name identification. All required documentation must be completed and submitted based on the specific insurance and safety requirements outlined for this on-call concrete maintenance and repair services contract. Companies with ten or fewer employees are exempt from providing a written safety program, and those exempt from OSHA Form 300A filing requirements must provide written explanation detailing the basis for such exemption.
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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 .