Exhibit L - Safety Evaluation.pdf
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- Attached to
- PSC - Church McKee Arts Center Stage Rigging
- Solicitation number
- RFP202690000659
- Issued by
- Mingo County, West Virginia
About this file
The document is a Contractor Safety Evaluation Pre-Qualification Questionnaire issued by West Virginia University's Procurement, Contracting and Payment Services department. The form is designed to assess a contractor's safety record and practices, with key evaluation criteria including the company's Experience Modification Rate (EMR), OSHA log information, safety program documentation, job site audit practices, employee training, and any previous OSHA citations.
The questionnaire requires detailed safety-related information from potential contractors, with specific requirements such as maintaining an EMR below 1.20, documenting OSHA recordable incidents, lost work days, total employee hours worked, and fatalities. Additional evaluation points include having a full-time Safety Director, conducting job site audits, holding regular "Tool Box Talks", requiring OSHA 30-hour training for employees, and maintaining a safety training program for foremen. The form was created in May 2016 and serves as a pre-qualification screening mechanism to ensure contractors meet West Virginia University's safety standards before being considered for contract work.
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Text version
Created May 2016 Phone: 304-293-5711 Fax: 304-293-8152
PO Box 6024 Morgantown WV 26506-6024
Procurement, Contracting and Payment Services
Contractor Safety Evaluation Pre-Qualification Questionnaire
1. List your company’s Experience Modification Rate (EMR) for the past three years; an EMR greater than 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
Created May 2016
Phone: 304-293-5711
One Waterfront Place, 3rd Floor PO Box 6024 Morgantown WV 26506-6024
Procurement, Contracting and Payment Services
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?
Created May 2016 Phone: 304-293-5711
PO Box 6024 Morgantown WV 26506-6024
Procurement, Contracting and Payment Services
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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