Safety Index Rating Form - Virginia Department Of Transportation printable pdf download

Safety Index Rating Form - Virginia Department Of Transportation

Form C-38

10-3-07

VIRGINIA DEPARTMENT OF TRANSPORTATION

Safety Index Rating Form

Date:____/____/____

Vendor Number_________

Firm Name: ________________________________________________________________

Contact Person___________________________________________________________

Address:______________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

Telephone Number: (

)

Facsimile Number: (

)

Requirements of this form include provisions for the evaluation of a new or existing firm’s safety

record.

The Safety Index Score of this evaluation will count 30% toward the firm’s

prequalification score. The Contractor’s Performance Evaluation will account for the remaining

70%. An original Safety Index rating form is required to be submitted annually with the firm’s

prequalification submissions. This evaluation is to be completed and signed by an authorized

person whose signature is on file in the prequalification office of the Scheduling and Contract

Division.

The submission of this form must include a letter from the firm’s insurer indicating the EMR numbers,

and applicable OSHA 200/300 logs as well as any OSHA/ VOSHA citations or VDOT issued

suspensions referenced in Part II questions 3, 4 & 5.

The maximum score for this evaluation is 300. The Contractor’s score is determined by deducting the

sum of the points calculated in Part I and Part II and deducting it from 300.

Safety Index Score: 300 – (Part I Total Points) - (Part II Total Points) = __________

_____________________________________________________________________________________

__________________________________OFFICIAL USE ONLY_____________________________

Safety Index Rating: __________

Prequalification Expires: __________

Approved By: ________________

Date: _______________

Notes:________________________________________________________________________

______________________________________________________________________________

Safety Index Rating Form - Virginia Department Of Transportation