8-H. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Solicitation number
- FY26-RFP-29
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form used by Charlotte Water in North Carolina for evaluating contractor qualifications for boiler, gas system, preventative maintenance, and repair services at water and wastewater treatment plants throughout Mecklenburg County. The form requires prospective contractors to provide organization information including company name, on-site representative contact details, and designated safety representative information. Contractors must submit documentation of their safety program, including a written safety and health program (unless the company has 10 or fewer employees), proof that employees are current on all applicable safety training, OSHA Form 300A annual summaries for the past three years, and copies of any OSHA citations or violations from the past three years. Additionally, contractors must provide their North American Industrial Classification System (NAICS) code and their Disease and Injury Rate (DART) incidence rates for the past three years, along with the industry standard DART rate for comparison purposes.
The form also mandates submission of comprehensive insurance coverage documentation, which must include copies of workers' compensation certificates of insurance, commercial general liability certificates, automobile liability certificates, and professional liability certificates for errors and omissions where applicable. All required insurance documentation must be submitted based on the scope of the project or contract requirements. The authorized representative of the contracting company must sign and date the completed assessment form with printed name included to certify the accuracy and completeness of 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:
File details come from the government source that posted it. Updated .