Exhibit C Safety Questionnaire.pdf

EXHIBIT C PRE-AWARD CONTRACTOR CONSTRUCTION SAFETY EVALUATION FORM

Company Name: ______________________________________________

Address: _____________________________________________________

Telephone: ___________________________________________________

Email: _______________________________________________________

Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

Category 2020 2021 2022 Number of man hours (jobsite and office).

Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).

Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).

Evaluating and considering past safety records of prospective contractors in awarding contracts. At a minimum, ensuring that all solicitations and contracts require documentation, to be supplied by potential contractors, that specifies the contractor in question has no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years.)

Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.

2. Who administers your company’s Safety and Health Program? __________________________________

3. Company’s Experience Modification Rate (EMR) (must be equal to or less than 1.0):_________________