Contractor_Safety_Evaluation_Form.pdf
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- Attached to
- Landscaping Services
- Solicitation number
- 2025-RFQ-009
- Issued by
- San Joaquin County, Sunnyvale City, Florida
About this file
This is a Contractor Safety Evaluation Form issued by the City of Lakeland's Risk Management and Purchasing Department for contractors seeking to work on infrastructure projects, particularly those involving systems covered by the Process Safety Management (PSM) Standard. The form serves as a pre-qualification document designed to assess contractor safety capabilities and compliance readiness. Contractors must submit comprehensive safety information including company details, accident statistics (Frequency Rate of Medical Injuries and Lost Time Injury Rate compared to national averages by SIC Code), and current Experience Modification Rate (EMR) from their insurance carrier. The evaluation requires documentation of safety practices such as regularly scheduled employee safety meetings, documented safety and health training programs for new employees, written safety programs, and field safety inspections for regulatory compliance. A critical requirement outlined in the form mandates that all contractors awarded work on PSM-covered systems must provide documentation that employees have received training on fire, explosion, and toxic release hazards specific to their job assignments, including employee identity, training date, and verification of understanding. Additionally, contractors must conduct Pre-Work Safety Assessments (PSA) or Job Hazard Analysis (JHA) for all work on PSM-covered systems, with all personnel reviewing the assessment at the beginning of work and as needed throughout the project, with any modifications requiring approval from the senior contractor supervisor and either the City of Lakeland Safety Manager or North McIntosh Plant Superintendent.
The form requires contractors to acknowledge their understanding of PSM Standard requirements by having a company officer sign the document with a definitive "Yes" or "No" response, and to provide detailed explanations of their intended compliance methods. Contractors are also given the opportunity to submit additional information demonstrating the value of their safety program. This evaluation form does not establish pricing terms, set-asides, or contract values, as it functions purely as a pre-qualification screening tool. The document serves as a prerequisite for contractors bidding on subsequent work orders and design packages that the City of Lakeland will issue as part of its infrastructure improvement initiatives, with the understanding that contractors must demonstrate sufficient resources and safety compliance to be considered for award of multiple work packages.
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Text version
City of Lakeland, Risk Management and Purchasing Contractor Safety Evaluation Form
Company Name P.O. Box
Street Address City State Zip Code
Business Contact Title Telephone Number
Safety Contact Title Telephone Number
What is your type of business? SIC Code
What is your company accident statistics for the Frequency Rate of Medical Injuries and Lost Time Injuries Rate as compared to the National Average for your industry as denoted by the Bureau of Labor Statistics for your SIC Code for the last three years? (*See explanation below)
Year Frequency Rate
National Average for your SIC Code
Lost Time Injury Rate
National Average for your SIC Code
*Frequency Rate is the number of injuries requiring medical attention multiplied by 200,000 divided by the number of Man-hours worked.
Example: Number of Accidents Requiring Medical Attention X 200,000 Number of Man-hours
*Lost Time Injury Rate is the number of Lost Time Injuries multiplied by 200,000 divided by the number of Man-hours worked, not considering injuries that only caused restricted work activity as Lost Time Accidents.
Example: Number of Lost Time Accidents X 200,000 Number of Man-hours
What is your company’s current Experience Modification Rate (EMR)? (*Please attach a copy rating received on Insurance Company Letterhead.)
Do you conduct regularly scheduled Safety Meetings for your employees? ☐ Yes
(If yes, how often?) ☐ No
How do you document the safety meetings?
Who conducts the Safety Meetings?
Name Title
Do you have a documented Safety & Health training/orientation program for new employees? (Write any comments in space below)
☐ Yes
☐ No
Do you have a written Safety Program? (Write any comments in space below) ☐ Yes
Do you conduct field Safety Inspections to determine compliance with state, federal, local and company regulations/procedures?
☐ Yes
☐ No If yes please provide the following:
Name Title
How do you follow up the inspections to ensure any needed corrections are made?
Does your company understand that if they were awarded the following contract they must do the following?
All contractors awarded work on the systems covered by the PSM Standard shall provide documentation that all employees have received training in the potential fire, explosion, or toxic release hazards related to his/her job and the process and the applicable provisions of the emergency plan. The documentation shall include the identity of the contract employee, the date of the training, and the means used to verify that the employee understood the training. In addition, a Pre-Work Safety Assessment (PSA) or Job Hazard Analysis (JHA) is required for all work on systems covered by the PSM Standard and the PSA or JHA must be reviewed by all personnel involved in the work beginning and as needed during the process of work. Any modification to the PSA or JHA during the job must be approved by the senior contractor supervisor on site and either the City of Lakeland Safety Manager, or the North McIntosh Plant Superintendent, or their designees.
Please have an officer of the company indicate “Yes” or “No” as an answer pertaining to the question above and sign in the space below:
☐ Yes
Name Date
How do you intend to comply with these requirements?
Do you have any other information you believe would be valuable in evaluating your company’s safety program? If so, please explain or attach to this document.
File details come from the government source that posted it. Updated .