FORM S SAFETY QUESTIONNAIRE Form S Table 1 shall be completed by the Proposer for the Key Personnel indicated. Form S Table 2, Items 1-8 must be completed for the Constructor(s), Construction Inspection Firm(s) and the Materials Testing Firm(s) as listed in the SOQ. Forms S, Table 2, Items 9 and 10, shall be completed for the Design Firm(s). Form S Table 1 SAFETY QUESTIONNAIRE FOR PROPOSER NAME OF PROPOSER To be completed by the Proposer. Indicate the safety record on the most recent project to which the indicated Key Personnel were assigned. Number of Total hours Number of Number of cases with Number of NAME OF by all lost restricted medical fatalities KEY MOST employees workday workday attention on that PERSONNEL RECENT on that cases on cases on only, on that project PROJECT project that project that project project (number) (hours) (number) (number) (number) Project Manager Resident Engineer Form S Table 2 SAFETY QUESTIONNAIRE FOR EACH FIRM
FORM S SAFETY QUESTIONNAIRE Form S Table 1 shall be completed by the Proposer for the Key Personnel indicated. Form S Table 2, Items 1-8 must be completed for the Constructor(s), Construction Inspection Firm(s) and the Materials Testing Firm(s) as listed in the SOQ. Forms S, Table 2, Items 9 and 10, shall be completed for the Design Firm(s). Form S Table 1 SAFETY QUESTIONNAIRE FOR PROPOSER NAME OF PROPOSER To be completed by the Proposer. Indicate the safety record on the most recent project to which the indicated Key Personnel were assigned. KEY PERSONNEL NAME OF MOST RECENT PROJECT Total hours by all employees on that project (hours) Number of lost workday cases on that project (number) Number of restricted workday cases on that project (number) Number of cases with medical attention only, on that project (number) Number of fatalities on that project (number) Project Manager Resident Engineer Form S Table 2 SAFETY QUESTIONNAIRE FOR EACH FIRM