Safety Index Rating Form - Virginia Department Of Transportation (Page 2 of 4) in pdf

Form C-38

10-3-07

PART I: Contractor’s Safety Philosophy Profile

(20 Points)

Listed below are questions to be used to determine your company’s overall safety philosophy

profile. Please provide the answer that best describes your company’s present business approach

and attitude towards safety.

1. Does your company have a designated safety manager?

_____Yes _____No

If so please provide:

Company Safety Manager: Name: ___________________________

Phone: ________________

2. Does your company provide pre-employment drug screening for all potential field employees?

_____Yes _____No

3. Are regular safety meetings held on project sites with all on-site employees?

_____Yes _____No

4. Does your company check motor vehicle records for all employees who operate company

vehicles?

_____Yes _____No

5. Are all company employees provided with formal safety training?

_____Yes _____No

If so provide a brief synopsis of the types of formal safety training provided to your employees

and the date of the most recent training offered:

___________________________________________________________________________

Part I: Point Total (total number of “No” responses x 4):

_________

Safety Index Rating Form - Virginia Department Of Transportation Page 2