Attachment 6_Safety Questionnaire.pdf
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- Solicitation number
- 80KSC026R0007
About this file
This document is an Attachment 6 Safety Questionnaire for Solicitation 80KSC026R0007, a Launch Complex (LC) 39 Area Duct Bank System Replacement project. The questionnaire requires detailed safety information from potential contractors, including OSHA violation history, injury prevention program status, safety meeting frequencies, and critical safety performance metrics such as Experience Modification Rate (EMR), Total Recordable Case Incident Rate (TCIR), and Days Away, Restricted or Transfer Case Incident Rate (DART) for the years 2022-2025. The form mandates comprehensive disclosure of safety performance, with specific requirements like providing explanations for EMR rates of 1.00 or higher, and notes that lacking an injury prevention program is grounds for disqualification.
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ATTACHMENT 6 – Safety Questionnaire
80KSC026R0007 – Launch Complex (LC) 39 Area Duct Bank System Replacement
Attachments and explanations provided on a separate page, as requested in the questions below shall not be counted against Offeror’s page count limit.
1. Has Federal OSHA or any state agency cited and assessed penalties against the entity or any of its affiliates for any “serious,” “willful” or “repeat” violations of its safety or health regulations in the past five (5) years?
Yes No
If “yes,” on separate page describe the citations, state the case number, the party against whom the citation was made, date of citation, nature of the violation, project on which the citation was issued, owner of project, and the amount of penalty paid, if any.
2. Does the entity have an injury prevention program instituted pursuant to Occupational Safety and Health requirements?
(A “No” answer is grounds for disqualification. There is no other or separate scoring of this answer.)
Yes No
3. At what frequency does the entity require documented safety meetings to be held for construction employees and field supervisors during the course of a project?
Weekly Monthly Other
If other, please describe:
4. List the entity’s Experience Modification Rate (EMR) for each of the past three (3) premium years:
(NOTE: An Experience Modification Rate is issued to your firm annually by your workers’ compensation insurance carrier.)
2025 (if available):
2024:
2023:
2022:
*If your EMR for any of these three (3) years is 1.00 or higher, you must attach a one (1) page explanation.
5. List the entity’s Total Recordable Case Incident Rate (TCIR):
2025 (if available):
2024:
2023:
2022:
6. List the entity’s Days Away, Restricted or Transfer Case Incident Rate (DART):
2025 (if available):
2024:
2023:
2022:
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