Title Page
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Contractor Name
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Address
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Name of Contact Person
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Contact Phone Number
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Contact Email
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Date of submission
Safety History
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Number of first aid accidents during the past 3 years
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Number of accidents requiring medical attention during the past 3 years
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Number of lost time accidents during the past 3 years
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Total number of days off work due to accidents during the past 3 years
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Number of fatalities during the past 3 years
- No fatalities
- 1 in the 3rd year and none since then
- More than 1 in the 3rd year or 1 or more in the last 2 years
Compliance
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Written orders to comply or convictions under safety regulations in the past three years
- No written orders or convictions
- 1-2 written orders or convictions with corrective actions taken
- 3-4 written orders or convictions with corrective actions taken
- 5+ written orders or convictions
Written Safety Programs, Policies, and Procedures
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Does your company have a written health and safety policy? (If yes, attach a copy of the policy)
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Does your company have specific health and safety programs? (If yes, attach a copy of the<br>programs)
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Does your company hold separate meetings to address safety issues?
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If yes, who attends these meetings?
- All employees
- Field employees including supervisors
- Field employees excluding supervisors
- Supervisors/Workers only
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Do you conduct a pre-project hazard analysis? (If yes, provide a copy of a completed hazard<br>analysis)
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Do your crews conduct daily pre-work tailboard/toolbox meetings before the start of each<br>shift/job? (If yes, provide three (3) examples of completed TBT forms)
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Does your company conduct safety orientations for all newly hired employees?
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Does your company provide safety training to your employees?
- Comprehensive training and orientations provided
- Basic training and orientations provided
- No training or orientations provided:
Additional Documentation
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Is there any additional documentation that supports your safety practices and history?
