Pre-Qualification Attachment II: Contractor Safety Record

 I. Contractor Information  

Contractor Name

Address (250 Char Limit)

Phone Number

E-mail Address


 II. Experience Modification Rate  

List Experience Modification Rate (New York - EMR) for the past three, full years and the current year.
Note: You are required to include copies of insurance carriers records

Year EMR
Current Year
Last Year
Two Years Ago
Three Years Ago

 III. DART Rate  

Please provide the DART rate for the given years from OSHA No. 300 & 300A:

Current Year
Last Year
Two Years Ago
Three Years Ago

 IV. Safety Information  

Please provide responses to the following safety questions:

A.  How often are job site foremen's safety meetings held?

B.  How often are toolbox safety meetings held?  What is discussed?

C.  Are regular safety inspections conducted? How often?

D.  Do you have an accident investigation procedure?  Define:

E.  Do you trend non-compliance safety findings?


F.  Planning discussions with employees i.e.: safe work place, phase hazard analysis, etc...? 


 V. Submittals  

Do you have the following programs?

Program Type Yes No
Assured Equipment Grounding
Drug Free Workplace
Lockout/Tag Out
Quality Assurance
Restrictive Work Program

If you answered yes to any of these questions, please provide copies of the programs.  In addition, please submit the following:

A.  Copies of OSHA No. 300 & 300A for the current year and past three years.

B.  Verification by your insurance carrier of the EMR listed in Item No. II above for the current year and past three years inclusive of explanation if EMR is greater than 1.00.

C.  Your written safety program including safety orientation for new hires and any additional training for foreman.  Click here to view the BNL Health and Safety Plan Template.

D.  Your hazard communication program.

E.  Any OSHA violations, citations, and/or fines you have had within the past three full years and the current year.


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Last Modified: September 25, 2012
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