8-I. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Solicitation number
- FY27-RFP-04
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form associated with Charlotte Water's procurement for outfall solids cleaning and removal services at the Irwin Creek Wastewater Treatment Plant in North Carolina. The form serves as a pre-qualification document requiring contractors to demonstrate safety compliance and insurance coverage before contract award. Contractors must submit comprehensive safety documentation including written safety and health programs, current employee training certifications, OSHA Form 300A summaries for the past three years, and any OSHA citations or violations from the same period. Additionally, contractors must provide their NAICS code and DART (Days Away, Restricted, or Transferred) incidence rates for the past three years to allow comparison against industry benchmarks.
The assessment form mandates submission of insurance documentation as a prerequisite for contract consideration, specifically requiring certificates of insurance for workers' compensation, commercial general liability, automobile liability, and professional liability for errors and omissions where applicable. The form includes exemptions for companies with ten or fewer employees regarding written safety program requirements and provides guidance directing contractors to the Bureau of Labor Statistics website for NAICS code identification. All submissions require authorization by an authorized company representative with printed name, signature, and date, ensuring accountability and legitimacy of submitted safety and insurance 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 .