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

Safety Index Rating Form - Virginia Department Of Transportation Page 4

Form C-38

10-3-07

4. Within the last two years, has your company received any final citations classified by OSHA or

VOSH as being willful in Virginia? _____Yes _____No

If so, how many citations: ______.

Attach copy(ies) of the citation(s).

Points: ______

Scoring: 0 Points if answered “No”. If yes, 15 points for each citation not to exceed 60 points.

5. Has your company within the last three years received any formal written suspensions by the

Virginia Department of Transportation for violation of one of the safety emphasis areas below?

If applicable, attach a copy of each written suspension.

Date Issued

Excavating, Trenching, or Shoring:

______Yes ______No

_________

Fall Protection:

______Yes ______No

_________

Crane Safety:

______Yes ______No

_________

Equipment Safety Devices (backup alarms, etc.): ______Yes ______No

_________

Workzone Traffic Control:

______Yes ______No

_________

Points: ______

Scoring: 15 points for each response of “Yes” not to exceed 60 points.

Part II: Point Total:

_________

(sum of points from questions 1 - 5)

PART 3: Certification

I hereby certify that the information provided in this document is true and accurate to the best of

my knowledge. Material misrepresentations in any section shall be reason for discounting some

or all points that the sections allows toward prequalification.

Signature: ________________________________

Date: _________________________

Name: ______________________________ Title: _______________________________

(print or type)

North American Industry Classification System codes (2002)

237310: Highway and Street Construction except Elevated Highways

237310: Bridge and elevated highway construction

237990: Tunnel Construction

238210: Highway lighting and signal installation

238320: Bridge Painting

If your company performs multiple classifications listed above along with Highway and Street construction, use

NAICS Code 237310.

For additional NAICS codes, contact OSHA of the U. S. Department of Labor or visit their website.

Safety Index Rating Form - Virginia Department Of Transportation Page 4

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