14. subcontractorFormIIPP.docx

SLAC Environment, Safety, and Health Manual Chapter Error! Unknown document property name.: Worker Safety and Health Program Acknowledgement Form SLAC National Accelerator Laboratory Environment, Safety & Health Division Chapter 42 | Worker Safety and Health Program Acknowledgement Form

Environment, Safety & Health Division Chapter 42: Subcontractor Safety Injury and Illness Prevention Program Acknowledgement Form Product ID: 509 | Revision ID: 2361 | Date Published: 7 September 2020 | Date Effective: 9 September 1999 URL: https://www-group.slac.stanford.edu/esh/eshmanual/references/subcontractorFormWSHP.pdf

Submission of this completed form is a prerequisite for issuance of the notice to proceed.

To be completed by the vendor representative. (Note a separate form must be submitted for all sub-tier subcontractors)

Purchase Requisition Number:

Supplier / Vendor:

Prepared by (foreman / supervisor for the job if possible): Phone: Cell Phone:

Supplier / Vendor Point of Contact: Phone: Cell Phone:

SLAC Injury and Illness Prevention Program (IIPP) Compliance

As a subcontractor to SLAC, you fall under the requirements of the SLAC IIPP while your workers are physically located at SLAC. As such, you must be aware of, and comply with, the requirements of the SLAC IIPP requirements. Alternatively, you have the option to develop and submit your own IIPP for SLAC review and approval. Furthermore, SLAC requires prime subcontractors to flow these requirements down to the sub-tier subcontractors that they hire. You can find further details about these requirements at the SLAC “Injury and Illness Prevention Program (IIPP)” website. This information is provided only as a guide – it is your responsibility to ensure you have read and understand the actual regulatory requirements.

Name: Signature: Date:

I certify that that I have read the requirements of the SLAC IIPP and attest that our work on this subcontract will comply with the requirements of SLAC’s IIPP or have, alternatively, developed an IIPP that is as-protective as the SLAC IIPP.

Will you have any employees that will work on-site at SLAC for 30, 8-hour days in a twelve-month period, or are enrolled for any length of time in a medical or exposure monitoring program required by federal, state or local regulations (including, but not limited to: hearing conservation, respiratory protection, lead exposure, beryllium exposure, etc.)?

No Yes; If yes, you will need to have comprehensive occupational medicine services for your workers and comply with the Occupational Medicine requirements of the SLAC IIPP.

If you answered yes above, please provide your occupational medicine provider contact information:

Clinic/Physician:

Phone: E-mail:

If you have any questions in filling out this form, please contact the SLAC procurement specialist.

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