9-I. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- Media Buying Services for Storm Water Services
- Solicitation number
- FY27-RFP-01
- Issued by
- Mecklenburg County, Cleveland Town, North Carolina
About this file
This is a Contractor Safety Assessment Form used by Charlotte-Mecklenburg Storm Water Services (CMSWS) in North Carolina to evaluate contractor safety qualifications and compliance. The form requires contractors to provide comprehensive safety documentation including written safety and health program materials, proof that employees maintain current safety training, and OSHA Form 300A annual summaries for the previous three years. Contractors must also disclose any OSHA citations or violations from the past three years, provide their NAICS code for industry classification purposes, and submit their company's DART incidence rate (Days Away, Restricted, or Transferred) compared to industry standards for the same three-year period.
The form also requires submission of insurance documentation based on project scope, including workers' compensation certificates, commercial general liability coverage, automobile liability insurance, and professional liability insurance for errors and omissions where applicable. Contractors must identify an on-site representative and designated safety representative with contact information. The form includes a signature section requiring authorization and date verification. A written safety program is not mandatory for companies with ten or fewer employees, and companies exempt from filing Form 300A must provide written explanation of their exemption status.
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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 .