Supplier Contractor Questionnaire.doc

DOC document 367 KB Posted Nov 22, 2011

Attached to: ENG081 Non-Safety Potable Water Skid
Solicitation number: 159246
Issued by: Department of Energy Los Alamos National Laboratory

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Supplier Quality Assurance Questionnaire ENG-081.docx	DOCX document	Nov 22, 2011
eng081_NonSafetyPotableWaterSkid.pdf	PDF	Nov 22, 2011

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SUPPLIER / CONTRACTOR QUESTIONAIRE

Enter Dun and Bradstreet (DUNS) Number:

GENERAL INFORMATION

NAME OF COMPANY (Full Legal Name)

STREET ADDRESS

CITY - STATE - ZIP CODE

MAILING ADDRESS

CITY - STATE - ZIP CODE

TELEPHONE

FACSIMILE

E-MAIL

WEBSITE

TELEX/TWX/CABLE

OTHER

Type of Business (check box or boxes)

FORMCHECKBOX

CORPORATION OR COMPANY

FORMCHECKBOX

SUBSIDIARY

FORMCHECKBOX

DIVISION

FORMCHECKBOX

PARTNERSHIP

Name and location of Parent Company

DUNS No.

If a Division, enter name and location of

Corporate Headquarters

DUNS No.

If more than one DUNS number applies to your operation, attach additional explanatory page(s).

Type of Facility (check box or boxes)

FORMCHECKBOX

MANUFACTURER/FABRICATOR

FORMCHECKBOX

DISTRIBUTOR/

SUPPLY HOUSE

FORMCHECKBOX

ASSEMBLY/

SHOP

FORMCHECKBOX

MANUFACTURERS

REPRESENTATIVE

FORMCHECKBOX

CONSTRUCTION

FORMCHECKBOX

ARCHITECT/ ENGINEER

FORMCHECKBOX

TECHNICAL SERVICE

FORMCHECKBOX

GENERAL SERVICE

FORMCHECKBOX

OTHER (SPECIFY)

Enter Applicable SIC Codes:

D. Enter Applicable NAICS Codes (North America):

Date Business Founded:

Under Present Ownership Since:

Number of Employees (All Facilities) Manual:

Non-Manual:

Small, Disadvantaged, Women-Owned or Veteran Status

Check Applicable Boxes

FORMCHECKBOX

SMALL

FORMCHECKBOX

WOMEN-OWNED

FORMCHECKBOX

DISADVANTAGED:

FORMCHECKBOX

HUB ZONE

FORMCHECKBOX

VETERAN OWNED

FORMCHECKBOX

SERVICE DISABLED VETERAN OWNED

FINANCIAL INFORMATION (This section MUST BE COMPLETED for consideration. Information is kept CONFIDENTIAL.)

Banking Reference:

Annual Sales Volume (Last 3 Years):

Present Net Worth

Bank Phone No.

Can you furnish a Performance Bond?

FORMCHECKBOX

Yes

FORMCHECKBOX

If “Yes”, indicate dollar limits.

To $250,000

To $500,000

To $1,000,000

To $5,000,000

To $10,000,000

$25,000,000 and up

Surety

Agent

Phone No.

If required, can you furnish a Bank Guarantee or Letter of Credit?

FORMCHECKBOX

Yes

FORMCHECKBOX

If "Yes," indicate dollar limits below:

FORMCHECKBOX

To $250,000

FORMCHECKBOX

To $500,000

FORMCHECKBOX

To $1,000,000

FORMCHECKBOX

To $5,000,000

FORMCHECKBOX

To $10,000,000

FORMCHECKBOX

$25,000,000 and Up

Surety

Bank

Phone No.

E. Current Financial Ratios (Public companies only)

Working Capital / Total Assets

Retained Earnings / Total Assets

Earnings Before Interest and Taxes / Total Assets

Market Value of Equity / Total Liabilities

Sales / Total Assets

F. Current Financial Ratios (Private companies only)

(Current Assets-Current Liabilities) / Total Assets

Retained Earnings / Total Assets

Earnings Before Interest and Taxes / Total Assets

Book Value of Equity / Total Liabilities

Sales / Total Assets

PERSONNEL (For this location –State “Not Applicable” if the position does not exist at this location)

President:

Engineering Manager:

Sales Manager:

QA/QC Manager:

Production Manager:

Field Support Manager:

LABOR RELATIONS – Shop Fabrication

(List all crafts with which you have contracts and/or working agreements. Check here if not applicable:

FORMCHECKBOX

CRAFT

EXPIRATION DATE

CRAFT

EXPIRATION DATE

PLANT OPERATIONS (For this facility only. Use a separate Page 2 for other facilities) Check here if not applicable

FORMCHECKBOX

Name/Address of This Facility (if different than for facility named at top of Page 1)

Name

Address

Phone

Facsimile

Number of Employees at This Facility:

Plant in Operation Since:

Do you have a Quality Assurance/ program written to comply with the following:

Nuclear related activities – 10CFR 830, Subpart A and DOE Order O 414.1C, Contractor requirements document (Attachments 2, 3 and 4) as implemented through a quality assurance program compliant with ASME NQA-1-2008, with 2009 addenda.

Other: Specify_______________________________________________________________________________________________________

Non Nuclear related activities – 10 CFR 830, Subpart A and DOE Order O 414.1.C, Contractor requirements document (Attachments 2, 3 and 4) as implemented through a quality assurance program compliant with ISO 9001-2000

Other: Specify_______________________________________________________________________________________________________

Nuclear

FORMCHECKBOX

Yes

FORMCHECKBOX

Other Certification (Please Specify)

ISO 9001

FORMCHECKBOX

Yes

FORMCHECKBOX

Other Certification (Please Specify)

For your Quality Assurance/Quality Control program(s), attach the Table of Contents from relevant manual(s) or, on additional pages, describe the method and level of compliance standard(s).

Export Capabilities

PROVIDE EXPORT PACKING?

FORMCHECKBOX

YES

FORMCHECKBOX

FAMILIAR WITH EXPORT FORMALITIES?

FORMCHECKBOX

YES

FORMCHECKBOX

Shipping Facilities

RAIL SIDING

FORMCHECKBOX

TRUCK DOCKS

FORMCHECKBOX

WATER ACCESS

FORMCHECKBOX

WATER ACCESS DRAFT _____ meters

BIDDING INTEREST AND QUALIFICATIONS

Indicate your relebant experience and qualifications as described in the attached “Scope of Work”.

(Attach additional pages if necessary)

Indicate appropriate Contract/Purchase Order dollar range within which you prefer, and are currently able, to bid (i.e., $250,000 to $1,500,000) to $

Indicate Industry or Code Certifications (ASME, API, TEMA, Class of Code-Stamp, etc.)

CERTIFICATION

EXPIRATION DATE

CERTIFICATION

EXPIRATION DATE

Subcontract Services (List type of work normally subcontracted to others)

7. PROFESSIONAL LICENSES

Indicate the work category you are licensed for and the area(s) (Country/State/Province) in which you hold each. Attach additional pages, if necessary.

TYPE OF LICENSE

LOCATION

TYPE OF LICENSE

LOCATION

8. ENGINEERING, ARCHTECTURAL AND OTHER TECHNICAL SERVICES CONTRACTORS / SPECIFIC DATA LISTINGS

A. In addition to circling applicable work categories in Appendix A (Goods and Services Codes), also indicate fields of specialization by your firm (i.e., chemical engineering, hydrology, geology, ecological surveying, etc.) on the bottom of the appendix.

B. List Personnel by Discipline (Number on Staff)

Administrative

Electrical Engineers

Oceanographers

Architects

Estimators

Planners (Urban/Regional)

Chemical Engineers

Geologists

Sanitary Engineers

Construction Inspectors

Interior Designers

Specification Writers

Draftsman

Landscape Architects

Structural Engineers

Ecologists

Mechanical Engineers

Surveyors

Economists

Mining Engineers

Transportation Engineers

WORK HISTORY (Complete the attached Work History form per Appendix “C” and attach to this Questionnaire)

Also attach a list of permanent offices and any brochures that further describe your company's activities and capabilities. Please do not include product catalogs, inventory or price lists.

10. SAFETY & HEALTH EXPERIENCE (Complete the attached S&H form per Appendix “D” and attach to this Questionnaire)

11. SOCIAL AND ENVIRONMENT SUSTAINABILITY INITIATIVES (Check all that are employed through company initiatives)

FORMCHECKBOX

Written environmental policy

FORMCHECKBOX

Products that have achieved "Cradle-to-Cradle" certification

FORMCHECKBOX

Environmental performance integrated into corporate mission

FORMCHECKBOX

Policies and practices to minimize fuel usage or use of alternative energy

FORMCHECKBOX

Social performance integrated into corporate mission

FORMCHECKBOX

Initiatives to mitigate environmental impacts of finished products

FORMCHECKBOX

Annual report detailing its mission-related performance

(e.g. corporate social and environmental targets)

FORMCHECKBOX

Code of conduct holding subsuppliers accountable for social and environmental performance

12. COMPLETED BY:

SIGNATURE

TITLE

NAME

DATE

APPENDICES:

APPENDIX “A” – GLOSSARY FOR SMALL, DISADVANTAGED, WOMEN-OWNED AND VETERAN ENTERPRISES

APPENDIX “C” – CONTRACTOR/SUPPLIER WORK HISTORY

APPENDIX “D” – CONTRACTOR SAFETY & HEALTH QUALIFICATION DATA

APPENDIX A

GLOSSARY FOR SMALL, DISADVANTAGED, WOMEN-OWNED, AND VETERAN ENTERPRISES

Following are definitions of small business concerns, veteran-owned small business concerns, service-disabled veteran-owned small business concerns, HUB Zone small business concerns, minority business enterprises, small disadvantaged business concerns, women-owned small business concerns and labor surplus area business concerns (all called “Enterprises”) as defined by the U.S. Federal Acquisition Regulations:

Small-Business Concern

Firms, including affiliates, that are independently owned and operated, not dominant in the field of operation in which they are bidding on Government contracts, and that qualify under the criteria and size standards for small businesses in 13 CFR Part 121 as determined by the SBA.

HUB Zone

A historically underutilized business zone which is located within one or more qualified census tracts, qualified metropolitan counties, or lands within the external boundaries of an Indian reservation. HUBZone’s appear on the List of Qualified HUBZone Small Business Concerns maintained by the SBA.

Veteran-owned Small Business Concern

A small business concern – (1) not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and (2) the management and daily business operations of which are controlled by one or more veterans.

Service-disabled Veteran-owned small Business Concern

(1) A small business concern – (i) not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and (ii) The management and daily business operations of which are controlled by one or more service-disabled or, in the case of a veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran. (2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16).

Small Disadvantaged Business Concern (Minority)

An offeror that represents, as part of its offer, that it is a small business under the size standard applicable to the acquisition; and either – It self certifies as a small disadvantaged business concern consistent with 13 CFR part 124, subpart B; and (i) No material change in disadvantaged ownership and control has occurred since its certification; (ii) Where the concern is owned by one or more disadvantaged individuals upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2); and (iii) It is identified, on the date of its representation, as a self certified small disadvantaged business concern in the database maintained by the SBA (Central Contractor Registration (CCR)).

Women-Owned Small Business Concern

A small business concern – 1) which is at least 51 percent owned by one or more women: or in the case of any publicly owned business, at least 51 percent of the stock which is owned by one or more women; and 2) whose management and daily operations are controlled by one or more women.

APPENDIX C

CONTRACTOR/SUPPLIER WORK HISTORY

The Contractor submits the following statement as to its experience qualifications:

If stated in the cover letter, provide only experience in work similar in type and magnitude to the identified Work Scope.

All awarded contracts have been satisfactorily completed, except as follows (Name any and all exceptions and reasons therefore, attaching additional pages if necessary):

The following contracts are currently in progress or have been satisfactorily completed within the last three years or the period specified in the cover letter.

If you have not worked in the country specified in the cover letter within the period outlined in 3 above, add a separate page listing any work ever performed in that country. [Item 4 does not apply to U.S. work.] 5.

Column Completion Notes:

a. Name and Address. For past Bechtel work, include Bechtel Job No. and also asterisk any work requiring nuclear quality assurance.

b. Work Description. Describe work scope and then indicate if prime or subcontract.

c. Start/Stop. Provide starting date and actual/forecast completion by mo/yr, e.g., Jan 93/Sep94.

d. Schedule and Budget. State either "over", "on", or "under" the contract schedule and budget.

Contractor/SUPPLIER WORK HISTORY

Customer Name, address, representative and phone no.

Work Description

Location

Value

Start/Stop

Schedule

Budget

List any awarded Contracts/Purchase Orders that were not satisfactorily completed: (List any and all exceptions and reasons therefore, attaching additional pages if necessary):

APPENDIX D

CONTRACTOR SAFETY AND HEALTH QUALIFICATION DATA

NAME OF COMPANY:

The above named Company submits the following Safety & Health qualification data:

SAFETY PERFORMANCE

1.1.a Provide a brief description of each fatality your firm has incurred in the three most recent years (add pages if required):

Year 20[ ]

1.1.b Provide a brief description of each fatality by any sub-tier subcontractor working under your direction has incurred in the three most recent years (add pages if required):

Year 20[ ]

1.2.a Provide the following information on your firm for the three most recent years:

20[ ]

20[ ] a.

Number of lost workday cases.

Number of restricted workday cases.

Number of cases with medical attention only.

Number of fatalities.

Number of hours worked.

1.2.b Provide the following information on any sub-tier subcontractor working under your direction for the three most recent years:

20[ ]

20[ ] a.

Number of lost workday cases.

Number of restricted workday cases.

Number of cases with medical attention only.

Number of fatalities.

Number of hours worked.

Are accident reports and report summaries sent to the following and how often?

Yes

Monthly

Quarterly

Annually

Project Superintendent/Site Manager.

FORMCHECKBOX

Vice President/Manager of Construction

FORMCHECKBOX

Safety Director

FORMCHECKBOX

President of Firm

FORMCHECKBOX

Do you hold site safety meetings for field employees both Manual and Non-Manual?

Yes

FORMCHECKBOX

How Often?

Weekly

FORMCHECKBOX

Bi-Weekly

FORMCHECKBOX

Monthly

FORMCHECKBOX

Less Often, As needed

FORMCHECKBOX

Do you conduct project safety inspections?

Yes

FORMCHECKBOX

If yes, who conducts this inspection?

TITLE

HOW OFTEN?

How are accident records and accident summaries kept? How often are they reported?

Yes

Monthly

Annually

Accidents totaled for the entire company

FORMCHECKBOX

Accidents totaled by project

FORMCHECKBOX

(1) Subtotaled by superintendent

FORMCHECKBOX

(2) Subtotaled by foreman

FORMCHECKBOX

How are costs of individual accidents kept? How often are they reported?

Yes

Monthly

Annually

Costs totaled for the entire company

FORMCHECKBOX

Costs totaled by project

FORMCHECKBOX

(1) Subtotaled by superintendent

FORMCHECKBOX

(2) Subtotaled by foreman

FORMCHECKBOX

List key Safety and Health personnel planned for this project. Please list name and expected position. When a project has not been specified, list key company personnel.

NAME

POSITION

PROPOSED / CURRENT PROJECT

Do you have a written safety & health program?

Yes

FORMCHECKBOX

If yes, submit a copy for evaluation.

Do you have an orientation program for new hires?

Yes

FORMCHECKBOX

If yes, submit a copy for evaluation. Does it include instruction on the following?

Yes

Head protection

FORMCHECKBOX

Fire protection

FORMCHECKBOX

Eye protection

FORMCHECKBOX

First aid facilities

FORMCHECKBOX

Hearing protection

FORMCHECKBOX

Emergency procedures

FORMCHECKBOX

Respiratory protection

FORMCHECKBOX

Toxic substances

FORMCHECKBOX

Safety belts and lifeline

FORMCHECKBOX

Trenching and excavation

FORMCHECKBOX

Scaffolding

FORMCHECKBOX

Signs, barricades, flagging

FORMCHECKBOX

Perimeter guarding

FORMCHECKBOX

Electrical safety

FORMCHECKBOX

Housekeeping

FORMCHECKBOX

Rigging and crane safety

FORMCHECKBOX

Road Safety (Driving)

FORMCHECKBOX

10.

Do you have a program for newly hired or promoted foremen?

Yes

FORMCHECKBOX

If yes, submit a copy for evaluation. Does it include the following?

Yes

Safe work practices

FORMCHECKBOX

First aid procedures

FORMCHECKBOX

Safety supervision

FORMCHECKBOX

Accident investigation

FORMCHECKBOX

Toolbox meetings

FORMCHECKBOX

Fire protection and prevention

FORMCHECKBOX

Emergency procedures

FORMCHECKBOX

New worker orientation

FORMCHECKBOX

11.

Do you hold craft “toolbox” safety meetings?

Yes

FORMCHECKBOX

How Often?

Weekly

FORMCHECKBOX

Bi-Weekly

FORMCHECKBOX

Monthly

FORMCHECKBOX

Less Often, As needed

FORMCHECKBOX

12.

Do you have a written Hazard Communication program?

Yes

FORMCHECKBOX

If yes, how is it implemented on each project?

13.

Do you have/require Material Safety Data Sheets (M.S.D.S.) for material/chemicals/equipment?

Yes

FORMCHECKBOX

If yes, explain field procedure for informing craft workers about potential hazards:

14.

List three (3) client references that could verify the quality and management commitment of your safety program.

Name

Address

Phone No.

Contract/Supplier Questionnaire

Rev. 0

File details come from the government source that posted it. Updated Nov 14, 2017.