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Company Phone Number
Address
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Name
Phone Number
Email
Name
Phone Number
Email
Name
Phone Number
Email
1. List firm's Experience Modification Rate for the last three full years. Please also list the current year to date EMR.
2. Number of injuries/illnesses for the current year to data and the last three years (based on OSHA 300 Log; recordable injuries, and employee hours worked).
2025
2024
2023
4. Attach proof of insurance certificate
5. Attach a copy of the last 3 year's OSHA 300 Logs and YTD for current year. Include subcontractor data
Attach NAICS Code
Attach documentation of current year EMR
6. Has your firm ever had a fatality?
Yes
No
Year(s)
Attach a description of the circumstances and your firm's corrective action:
7. Has your firm received any citations in the past three (3) years from governmental agencies, e.g., federal or state OSHA, etc?
Yes
No
Attach a description of the circumstances and your firm's corrective action:
Applicable Safety Programs
Company safety policy
Company safety rules
Fall protection*
Emergency Action Plan*
Fire Prevention Plan*
PPE*
Respiratory Protection
Orientation training
Excavation and trenching*
Confined Space Entry*
Lockout/Tagout*
Hot work and Hex Chrome*
Electrical Safety*
Bloodborne Pathogens*
Hazard Communication*
Injury/Illness Recordkeeping*
Hearing Conservation*
Assured Eq. Ground/GFCI*
First Aid/CPR/AED
8. Does your firm have a written safety and health program e.g., policies and procedures?
Yes
No
9. Has your firm established a written safety and health training program?
Yes
No
11. Is all safety training documented?
Yes
No
12. What additional safety training do your supervisory personnel receive (foremen, crew, supervisors, etc.)?
13. Does your company have a new employee orientation training program?
Yes
No
14. Are safety meetings regularly conducted?
Yes
No
Are safety meetings documented?
Yes
No
Is there an established agenda for the safety meetings?
Yes
No
Are all crew members/employees required to attend??
Yes
No
Who is responsible for ensuring these meetings are conducted?
How often are meetings conducted??
15. Does your firm have a written disciplinary action policy relating to safety violations?
Yes
No
16. To what extent does your firm use professional safety & health staff?
Select
Outside safety consultants used
In-house safety professional on staff
Safety Department with Certified Professionals
17. To what extent does your firm use professional engineers?
Select
Outside engineering firm used
Professional Engineer on staff
Engineering Department with Registered Professional Engineer
Are safety and health inspections/audits conducted/documented?
Yes
No
19. Explain how identified conditions brought to closure?
Explain how identified conditions documented?
20. Is Safety a criteria in evaluating the performance?
Yes
No
Is Foreman safety evaluated?
Yes
No
Is Supervisors safety evaluated?
Yes
No
Is Management safety evaluated?
Yes
No
21. Please briefly describe how you accomplish this:
22. Any additional information to support your Company's commitment to safety:
Contractor agrees to comply with all Contractor Safety and Health Requirements (Attachment 2).
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