Engineering Vendor Safety Record Evaluation Form

Vendor Information

Vendor Name Contact Person Contact Number Evaluation Date

General Safety Performance

Years in Business OSHA Recordable Incidents (past 3 years) Lost Time Incident Rate (LTIR) Total Recordable Incident Rate (TRIR)

Safety Program

Does the vendor have a written safety policy/program? Yes No Does the vendor provide safety training for employees? Yes No

Incident History (Past 3 Years)

Year	Total Hours Worked	Number of Reportable Incidents	Number of Lost Time Incidents

Additional Comments

Comments

Evaluator Information

Evaluator Name Evaluator Signature Date