Welcome to the City and County of San Francisco (CCSF) Safety Prequalification Form (Form). This Form uses your documented and verifiable safety record and, if necessary, your safety documents, to gauge your safety culture. The CCSF wants to work with firms that value safe working environments for their employees, our employees, and the general public.
This web-based Form will ask for information and request additional information based on your responses. Your firm’s response may use only three parts of this Form or may need to use all eight parts of the Form. Here is a list of all eight parts:
It is possible to immediately pass the prequalification based on a previous submission or at Step 1 or Step 2. If you are required to provide information in Step 3, your safety documents and OSHA violation history will be evaluated by a Third-Party Safety Expert. The scoring rubrics for each Step 3 question can be found on the prequalification page of the SFPUC website. The results of your Step 3 evaluation, pass or fail, will be provided upon completion of the evaluation and concurrence by the Department. The detailed evaluation by the Third-Party Safety Expert will be provided post-bid.
Please follow the instructions for each portion of the Form. In Part 2, you will identify the CCSF Department that will receive your Form. We appreciate your desire to work with the CCSF and honor our continued desire for safe work sites!
This Form should be completed by the firm’s safety officer who will be signing the Acknowledgement under penalty of perjury under the laws of the State of California that all information submitted is accurate.
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Company Address
Company Safety Representative
This Part 3 is for contractors that passed the Safety Prequalification previously and want to rely on that passing result/score for this solicitation. Because firms create new OSHA Form 300 and Form 300A each March, the years of your prior submission matter and must match the Reference Years identified below. For the prior submission information, please be sure to list the first Safety Prequalification submission that used the correct Reference Years and included submission of the OSHA Form 300 and Form 300A. Please always rely on the first passing submission that used the same Reference Years.
You cannot rely on passing Step 3 evaluations that are more than six-months old.
Reference Years:
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Combine safety information for any and all construction work the Firm has completed as Prime, Joint Venture Partner or Subcontractor into one submission.
D. Please provide data from your firm's Occupational Safety and Health Administration (OSHA) Form 300A, Summary of Work-Related Injuries and Illness. The data should be for all construction work your firm performed whether as a prime, as part of a joint venture, or as a subcontractor.
Reference Year:
Total number of deaths (G)
Total number of cases with days away from work (H)
Total number of cases with job transfer or restriction (I)
Total number of other recordable cases (J)
Average number of employees
Total hours worked by all employees
Total recordable case rate
Total cases with days away from work, job restriction, or transfer rate
E. Please enter the North America Industrial Classification System (NAICS) information associated with your industry in the following available spaces. You can get to the OSHA website to obtain this information using links in the "Available Resources" section of the prequalification webpage on the SFPUC website.
Reference Year:
What is the NAICS Industry Code from your annual Form 300A?
What is the "Industry" description for your firm's NAICS code?
What is the annual "Total Recordable Cases" Rate for your Firm's NAICS Industry Code?
What is the annual "Total Work Loss" Rate for your Firm's NAICS Industry Code?
F. Is your firm's recordable case rate worse than industry standard for two of the last three years? (autocalculated; your annual reported data is compared to that year's OSHA Rate for your industry)
G. Has your firm received an OSHA Serious, Willful or Repeat violation in the last three years, regardless of appeal status?
H. Has your firm experienced a workplace fatality in the last three years?
Step 2.
I. Is your firm's Work Loss rate worse than industry standard for two of the last three years? (autocalculated based on previous inputs)
J. Has your firm received an OSHA Willful or Repeat violation in the last three years, regardless of appeal?
K. The annual total hours worked for last three (3) years by all employees as reported on your OSHA 300A form (autocalculated based on previous inputs).
L. Provide the number of Serious violations issued by OSHA over the last 36 months (different time period than the Reference 3 years of OSHA 300A forms), regardless of appeal status.
M. Your serious OSHA violation rate per 200,000 hours (autocalculated based on previous inputs)
N. Does your firm have more than one serious OSHA violations per 200,000 hours, regardless of appeal status? (autocalculated based on previous inputs)
O. Did OSHA issue your firm a citation for any incident in which there was a fatality in the last 3 years?
Step 3.
Your firm must be evaluated at Step 3 to pass the Safety Prequalification. Your firm may earn up to 300 points in the following categories:
The points are fully described on the prequalification page of the SFPUC website.
Negative points will be assigned to your firm based on the Third-Party Safety Expert’s review of Part 7: OSHA Violation History. Your firm must have a positive score of 150 to pass Step 3. The results of your evaluation, pass or fail, will be provided upon completion of the evaluation and concurrence by the Department. The detailed evaluation by the Third-Party Safety Expert will be provided post-bid. Please see the prequalification page on sfpuc.org for a description of the scoring rubrics for the OSHA violations.
NOTE: Applicants and Contractors may not revise their Step 3 safety documents after initial submission in order to pass the prequalification for this solicitation.
P. Safety Document SubmittalsMark each circle below if you can provide a document for the Third-Party Safety Expert to review. Document upload link will be provided after the form is submitted.
Document available for submission? (Yes/No)
Maximum Possible Score
Your Submission Score
P.1. Does your firm have an Injury and Illness Prevention Program?
10
P.2. Does your firm have a Drug and Alcohol Free Workplace Policy?
10
P.3. Does your firm have a Job Hazard Analysis (JHA) Procedure?
5
P.4. Does your firm have a Corporate Safety Manual?
5
P.5. Does your firm have an Injury and Incident Investigation Process?
5
P.6. Does your firms have any Employee Safety Training Programs?
5
P.7. Does your firm have a Safety Field Audit Process?
5
P.8. Does your firm have a Daily Safety Pre-Task Planning Process?
5
Total Document Submission Score (autocalculated and to be verified):
Step 3 (cont'd).
Each violation should only be listed once in the correct category. Do not list a violation multiple times - only once in the most appropriate category.
Applicant must provide copies of the citation, any appeal, and an explanation of any corrective actions taken. (Upload link will be provided after form is submitted.)
Q. OSHA Serious Violations
Please list violations for all construction work your firm performed whether as a prime, as part of a joint venture or as a subcontractor. Include Federal and State OSHA Serious violations issued over the last 36 months.
Date OSHA Opened Case
Citation #
Violation #
Standard
Citation Info Available? (Yes/No)
Appeal Available? (Yes/No)
Explanation of Corrective Action Available? (Yes/No)
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Date OSHA Opened Case
Citation #
Violation #
Standard
Citation Info Available? (Yes/No)
Appeal Available? (Yes/No)
Explanation of Corrective Action Available? (Yes/No)
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Provide a description and explanation for each fatality with citation.
Date of Fatality
Citation #
Violation #
Standard
Citation Info Available? (Yes/No)
Appeal Available? (Yes/No)
Explanation of Corrective Action Available? (Yes/No)
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Step 3 (cont'd).
This page calculates the Injury and Lost Work Rates Scores based on the information entered in Part 4. This score is transferred to the Third-Party Safety Expert’s evaluation form. The results of your evaluation, pass or fail, will be provided upon completion of the evaluation and concurrence by the Department. The detailed evaluation by the Third-Party Safety Expert will be provided post-bid.
T. Occupational Safety and Health Administration (OSHA) Form 300A Summary of Work-Related Injuries and IllnessReference Year:
Points
Current Total Recordable Rate from U.S. Department of Labor for Firm's NAICS (automatically populated from Part 4)
Total Recordable Rate (automatically populated from Part 4)
Possible maximum points
10
10
10
Points Earned for being equal to or better than industry rate (automatically calculated)
Current Total Work loss Rate from U.S. Department of Labor for Firm's NAICS (automatically populated from Question B)
Total cases with days away from work, job restriction, or transfer rate (automatically populated from Question A)
Possible maximum points
20
20
20
Points Earned for being equal to or better than industry rate (automatically calculated)
Total OSHA 300A Score
Click Proceed button below to complete and submit the Acknowledgement. After submission of your prequal form, you will receive an email with a link to upload the following documents. Please make a note of this now and start gathering documentation while you wait.
P.1. Injury and Illness Prevention Program
P.3. Job Hazard Analysis (JHA) Procedure
P.5. Injury and Incident Investigation Process
P.7. Safety Field Audit Process
You will receive a confirmation email shortly.