8-H. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- Water Treatment Valve Rehabilitation Services
- Solicitation number
- FY26-RFP-28
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form required by Charlotte Water for the Water Treatment Valve Rehabilitation Services contract opportunity in North Carolina. The form establishes safety and compliance requirements that prospective contractors must meet to be considered for valve inspection and rehabilitation services throughout Mecklenburg and surrounding counties. The assessment evaluates contractor qualifications across multiple safety and insurance dimensions to ensure operational readiness and minimize project risks.
The form requires contractors to provide comprehensive documentation including a written safety and health program, current employee safety training certifications, OSHA Form 300A annual summaries for the past three years, and any OSHA citations or violations from the same period. Contractors must also submit their NAICS code and Disease and Injury Rate (DART) incidence rates for the past three years compared against industry benchmarks. Additionally, contractors must provide certificates of insurance covering workers' compensation, commercial general liability, automobile liability, and professional liability for errors and omissions where applicable based on project scope. The form requires authorization by an authorized company representative with signature and date confirmation. Exemptions from certain documentation requirements are permitted for companies with ten or fewer employees, such as those not required to file OSHA Form 300A.
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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 .