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.