Contractor Safety Eval Pre Qual Questionnaire.pdf
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- Solicitation number
- RFB202690000695
- Issued by
- Mingo County, West Virginia
About this file
This is a Contractor Safety Evaluation Pre-Qualification Questionnaire issued by the Procurement, Contracting and Payment Services office for West Virginia in connection with the Mineral Resource Building Core Lab Renovation Phase II project at the Evansdale Campus in Morgantown, WV. The questionnaire is designed to assess contractor safety qualifications and performance across multiple dimensions. Prospective contractors must provide their Experience Modification Rate (EMR) for the past three years, with a maximum acceptable EMR of 1.20. Additionally, contractors must submit OSHA Log Information for the past three years, including total recordable cases, lost work days, total employee hours worked, and number of fatalities.
The questionnaire requires contractors to demonstrate established safety infrastructure and practices, including possession of a written Safety Program and designation of a full-time Safety Director or equivalent responsible party. Contractors must confirm whether they conduct documented job site audits, hold regular Tool Box Talks for employees, and provide OSHA 30-hour training to their workforce. The form also requests information regarding foreman safety training programs and requires disclosure of any OSHA citations received in the past three years, with detailed explanations if applicable. This pre-qualification evaluation serves as a screening mechanism to ensure that only contractors meeting West Virginia's established safety standards and performance thresholds are considered for the renovation project.
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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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