Contractor Safety Eval Pre Qual Questionnaire.pdf
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- Solicitation number
- RFB202690000696
- Issued by
- Mingo County, West Virginia
About this file
This is a Contractor Safety Evaluation Pre-Qualification Questionnaire issued by West Virginia University's Procurement, Contracting and Payment Services department for the PRT Guideway Bridge Bearing Replacement and Pier Repair project on WVDOT Bridge No. 31-19-13.06 in Morgantown, West Virginia. The questionnaire is designed to assess contractor safety qualifications and performance history prior to project award. Prospective contractors must provide their Experience Modification Rate (EMR) for the past three years, with a maximum allowable EMR of 1.20, and must submit detailed OSHA Log Information including total recordable cases, lost work days, total employee hours worked, and number of fatalities for the same three-year period.
The questionnaire requires contractors to demonstrate comprehensive safety program infrastructure and practices, including submission of written safety program documentation, identification of a full-time Safety Director or designated safety personnel, and evidence of job site audits with documentation of frequency and conducting party. Contractors must also provide information regarding employee safety training initiatives, including whether they conduct tool box talks with documentation frequency, require OSHA 30-hour training for employees, and maintain foreman safety training programs. Additionally, contractors must disclose any OSHA citations received within the past three years with detailed explanations of violations. This pre-qualification assessment establishes minimum safety standards and documentation requirements that contractors must satisfy before being considered eligible for award of the bearing installation and concrete repair work.
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Procurement, Contracting and Payment Services
Phone: 304-293-5711 Fax: 304-293-8152
150 Clay Street, 2nd Floor PO Box 6024 Morgantown WV 26506-6024
Created May 2016
Contractor Safety Evaluation Pre-Qualification Questionnaire
1. List your company’s Experience Modification Rate (EMR) for the past three years; an EMR of 1.20 will not be considered.
Year: Year: Year:
EMR: EMR: EMR:
2. List the following OSHA Log Information for the past three years:
OSHA Log Information Year: Year: Year:
Total Recordable
Lost Work Days Cases
Lost Work Days
Total Employee Hours Worked
Number of Fatalities
(Circle the applicable answer)
3. Do you have a written Safety Program?................................................................................................................................................Yes No
150 Clay Street, 2nd Floor PO Box 6024 Morgantown WV 26506-6024
Phone: 304-293-5711 Fax: 304-293-8152
Created May 2016
4. Do you have a full time Safety Director?................................................................................................................................................Yes No
a. If not, who is in charge of safety and what are their primary roles in this capacity?
5. Do you conduct job site audits?............................................................................................................................................................Yes No
a. By Whom?
b. How Often?
c. Is this documented? ?...............................................................................................................................................................Yes No
6. Do you hold “Tool Box Talks” for employees?.......................................................................................................................................Yes No
a. How Often?
b. Is this documented? ?...............................................................................................................................................................Yes No
7. Do you require employees to have OSHA 30-hour training?.................................................................................................................Yes No
8. Do you have a safety training program for the foreman?.................................................................................................Yes No
a. If yes, what does this include?
150 Clay Street, 2nd Floor PO Box 6024 Morgantown WV 26506-6024
Phone: 304-293-5711 Fax: 304-293-8152
Created May 2016
9. Has OSHA cited you in the past three years?.......................................................................................................................................Yes No
a. If yes, explain in detail (Add more pages as necessary):
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