ATTACHMENT B - Contractors Safety Form.docx
DOCX document 25 KB Posted
- Solicitation number
- 10161
- Issued by
- Colorado
About this file
The document is a Contractor Safety Form from the City of Fort Collins, Colorado, for an On-Call Construction Services project for Water Utilities & Natural Areas. The form is a comprehensive safety assessment tool designed to evaluate potential contractors' safety records, procedures, and capabilities. It requires detailed information about the company's safety management, including employee count, safety officer details, written safety programs, training protocols, equipment, and historical safety performance metrics such as Experience Modification Rate (EMR) and Total Recordable Incident Rate (TRIR).
The form includes specific evaluation criteria that may impact contractor eligibility, with companies having an EMR above 1.0 or TRIR above 5.0 subject to in-depth review and potential disqualification at the City's discretion. Contractors must provide three years of safety records, including injury and illness data, OSHA citations, and explanations for any elevated safety ratings. The form requires documentation of safety training, job hazard analyses, safety equipment for specialized activities like trenching and confined space work, and a description of the company's approach to maintaining safety compliance throughout project execution.
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Text version
ATTACHMENT B
CONTRACTOR SAFETY FORM
Please complete the following form to provide information about your Company’s safety records and procedures. This information will be included in the evaluation of the submitted proposal. We reserve the right to request additional documentation, at any point, that supports the accuracy of this form.
Contractor(s) safety record will be evaluated by the evaluation team as an element of determining whether the Contractor(s) is responsible. Contractor(s) whose safety record is above 1.0 for Experience Modification Rating (EMR) and 5.0 for Total Recordable Incident Rate (TRIR) will be reviewed in depth and may be deemed ineligible to be considered for award at the City’s sole discretion.
Section 1. General Information Company Name
| Number of Employees |
| Full Time: Part Time: Seasonal: |
Insurance Carrier
| Self-insured for Workers Compensation? |
| Y ☐ |
| N ☐ |
Section 2. Health and Safety Professional Information
| Does your company have a full-time dedicated Safety Officer? |
| Y ☐ |
| N ☐ |
If yes, provide the following information for the dedicated Safety Officer:
Name:
Title:
Phone Number:
Email:
If no, provide the following information of the person responsible for safety in your company:
Name:
Title:
Phone Number:
Email:
Provide the following information for the site safety Point of Contact:
Name:
Title:
Phone Number:
Email:
Section 3. Health and Safety Program
| Does your company have a written Company Safety Program? |
| Y ☐ |
| N ☐ |
| Does the written Company Safety Program cover the work activities proposed by your company for this project? |
| Y ☐ |
| N ☐ |
Does the written Company Safety Program include the following:
| Health and Safety Training |
| Y ☐ |
| N ☐ |
| Employee/Management Responsibility |
| Y ☐ |
| N ☐ |
| Hazard Recognition and Control |
| Y ☐ |
| N ☐ |
| Incident Reporting and Investigation |
| Y ☐ |
| N ☐ |
Describe a typical job site safety briefing (time, location, frequency, topics, documentation).
How does your company ensure health and safety program compliance throughout the project?
| Does your company perform written Job Hazard Analysis’s (JHA’s) regularly and document them? |
| Y ☐ |
| N ☐ |
How often does your company conduct Health and Safety audits or inspections?
| Does your company have a written corrective action plan for any findings? |
| Y ☐ |
| N ☐ |
Section 4. Training and Certifications List required safety training ALL employees receive:
List specialized safety training employees receive as needed:
| Does your company maintain records of all safety training and certifications? |
| Y ☐ |
| N ☐ |
Section 5. Safety Equipment (Engineered Controls)
| Will your company be performing any Trenching/Excavation and Confined Space Activities? |
| Y ☐ |
| N ☐ |
If yes, list what protective shoring equipment you will have available for the job site?
If entering Permit Required Confined Spaces (PRCS), such as vaults or sewers, what is your procedure for these activities?
Section 6. Health and Safety Records List the Company’s Experience Modification Rate (EMR) for the previous 3 years
| Year: |
| EMR: |
| Year: |
| EMR: |
| Year: |
| EMR: |
For any EMR greater than 1, provide an explanation for the rating and describe the corrective action taken by the Company. Use additional pages if needed.
Provide the number of injuries and illnesses recorded (OSHA 300 log or equivalent) in the previous 3 years:
| Calendar Year |
| Year: |
| Year: |
| Year: |
Number of Fatalities
Number of OSHA recordable cases
Number of OSHA modified duty cases
Number of OSHA lost time cases
OSHA Total Recordable Incident Rate (TRIR)
Number of recordable cases x 200,000 Number of hours worked
OSHA DART Rate (Days Away Restricted or Transferred)
Number of DART cases x 200,000 Number of hours worked
Average number of employees on payroll
| Have any OSHA citations been issued to your company in the past 3 years? |
| Y ☐ |
| N ☐ |
If yes, list the citations and for each, provide the type of violation, an explanation for the citation, the penalty issued, and describe the corrective action taken by the Company. Limit your response to projects that have occurred in the Rocky Mountain region. Use additional pages if needed.
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