REI_CP14SupplierSubcontractorQuestionnaire.docx
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- REI CP14 East RLUOB Safe Passage
- Solicitation number
- 173549
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Supplier Subcontractor Questionnaire
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SUBCONTRACTOR QUESTIONNAIRE
Enter Dun and Bradstreet (DUNS) Number:
1. GENERAL INFORMATION
NAME OF COMPANY (Full Legal Name)
| STREET ADDRESS |
| CITY - STATE - ZIP CODE |
| MAILING ADDRESS |
| CITY - STATE - ZIP CODE |
| TELEPHONE |
| FACSIMILE |
| WEBSITE |
| TELEX/TWX/CABLE |
| OTHER |
| A. | Type of Business (check box or boxes) |
| |_| | |
| CORPORATION OR COMPANY | |
| |_| | |
| SUBSIDIARY | |
| |_| | |
| DIVISION |
| |_| |
| 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).
| B. | Type of Subcontractor (check box or boxes) |
| |_| | |
| MANUFACTURER/ |
FABRICATOR*
| |_| |
| DISTRIBUTOR/ |
SUPPLY HOUSE*
| |_| |
| MANUFACTURERS |
REPRESENTATIVE*
| |_| |
| GENERAL CONTRACTOR |
| |_| |
| CONSTRUCTION* |
| |_| |
| ARCHITECTURAL/ ENGINEERING* |
| |_| |
| TECHNICAL SERVICE* |
| |_| |
| OTHER* |
* Specialization/Description As Follows:
C. Enter Applicable SIC Codes:
D. Enter Applicable NAICS Codes (North America):
E. Date Business Founded:
Under Present Ownership Since:
| F. | Number of Permanent Employees: |
| Manual: |
Non-Manual:
G. Small, Disadvantaged, Women-Owned or Veteran Status (Reference Questionnaire - Appendix “A” For Definitions)
| Check Applicable Boxes | |
| |_| | |
| SMALL | |
| |_| | |
| WOMEN-OWNED | |
| |_| | |
| DISADVANTAGED: | |
| |_| | |
| HUB ZONE |
| |_| |
| VETERAN OWNED |
| |_| |
| SERVICE DISABLED VETERAN OWNED |
2. FINANCIAL INFORMATION (This section MUST BE COMPLETED for consideration. Information is kept CONFIDENTIAL.)
A. Bank Name:
Agent:
Phone No.:
| B. | Annual Sales Volume (Last 3 Years): |
| Year: |
20___
| $ |
| Year: |
20___
| $ |
| Year: 20___ |
C. Present Net Worth
| D. Can you furnish a Payment and Performance Bond? |
| |_| Yes |
| |_| No |
| If “Yes”, indicate Max Dollar Limit: |
| |_| |
| $250,000 |
| |_| |
| $500,000 |
| |_| |
| $1,000,000 |
| |_| |
| $5,000,000 |
| |_| |
| $10,000,000 |
| |_| |
| >$25,000,000 |
Surety Name:
Agent:
Phone No.:
| E. | If required, can you furnish a Bank Guarantee or Letter of Credit? |
| |_| Yes | |
| |_| No |
| If “Yes”, indicate Max Dollar Limit: |
| |_| |
| $250,000 |
| |_| |
| $500,000 |
| |_| |
| $1,000,000 |
| |_| |
| $5,000,000 |
| |_| |
| $10,000,000 |
| |_| |
| >$25,000,000 |
Surety Name:
Agent:
Phone No.:
| F. Current Financial Ratios (Public companies only) |
| |_| |
| Not Applicable |
Working Capital / Total Assets
Retained Earnings / Total Assets
Earnings Before Interest and Taxes / Total Assets
Market Value of Equity / Total Liabilities
Sales / Total Assets
| G. Current Financial Ratios (Private companies only) |
| |_| |
| Not Applicable |
(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
3. PERSONNEL (State “Not Applicable” if the position does not exist )
A. President:
D. QA/QC Manager:
B. Sales Manager:
E. Field Support Manager:
C. Engineering Manager :
F. Safety Manager:
4. LABOR RELATIONS
| (List all crafts with which you have contracts and/or working agreements. | |
| |_| | |
| Not Applicable |
| CRAFT |
| EXPIRATION DATE |
| CRAFT |
| EXPIRATION DATE |
1.
3.
2.
4.
5. QUALITY
A. 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 | |
| |_| | |
| Yes | |
| |_| | |
| No | |
| Other Program (Please Specify) |
| ISO 9001 | |
| |_| | |
| Yes | |
| |_| | |
| No | |
| Other Program (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).
6. BIDDING INTEREST AND QUALIFICATIONS
A. Indicate your relevant experience and qualifications as described in the attached “Scope of Work”.
(Attach additional pages if necessary)
B. 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 $
C. Indicate Industry or Code Certifications (ASME, API, TEMA, Class of Code-Stamp, etc.)
| CERTIFICATION |
| EXPIRATION DATE |
| CERTIFICATION |
| EXPIRATION DATE |
1.
4.
2.
5.
3.
6.
D. 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 |
1.
4.
2.
5.
3.
6.
8. CONTRACTORS’ SPECIFIC NON-MANUAL, ENGINEERING, ARCHITECTURAL AND CONSTRUCTION TYPE LISTINGS:
A. List Personnel by Discipline (Number on Staff) – (State “Not Applicable” if the position does not exist )
Project Managers
Structural Engineers
Construction Inspectors
Administrators
Sanitary Engineers
Laborers
Estimators
Transportation Engineers
Carpenters
Architects
Technical Writers
Operators
Chemical Engineers
Surveyors
Painters
Electrical Engineers
Superintendants
Electricians
Mechanical Engineers
Foremen
Iron Workers
| 9. | WORK HISTORY (Complete the attached Work History form per Appendix “B” 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 “C” and attach to this Questionnaire)
11. SOCIAL AND ENVIRONMENT SUSTAINABILITY INITIATIVES (Check all that are employed or achieved through company initiatives)
| |_| Written environmental policy |
| |_| Leadership in Energy and Environmental Design (LEED) Certification |
| |_| Environmental performance integrated into corporate mission |
| |_| Policies and practices to minimize fuel usage or use of |
alternative energy
| |_| Social performance integrated into corporate mission |
| |_| Initiatives to mitigate environmental impacts of on-site services |
|_| Annual report detailing its mission-related performance (e.g. corporate social and environmental targets) |_| Code of conduct holding sub suppliers 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 “B” – CONTRACTOR/SUPPLIER WORK HISTORY
APPENDIX “C” – CONTRACTOR SAFETY & HEALTH QUALIFICATION DATA
| Subcontractor Questionnaire | Page 1 of 3 |
| Rev. 02, Dated September 16, 2011 | 173549-RFP, REI CP -14 – East RLUOB Safe Passage |
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 B
SUBCONTRACTOR WORK HISTORY
The Contractor submits the following statement as to its experience qualifications:
| 1. | If stated in the cover letter, provide only experience in work similar in type and magnitude to the identified Work Scope. |
| 2. | All awarded contracts have been satisfactorily completed, except as follows (Name any and all exceptions and reasons therefore, attaching additional pages if necessary): |
| 3. | 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. |
| 4. | 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 work, include an asterisk (*) to identify any work that required 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 C
SUBCONTRACTOR SAFETY AND HEALTH QUALIFICATION DATA
NAME OF COMPANY:
The above named Company submits the following Safety & Health qualification data:
1. 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[ ]
Year 20[ ]
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[ ]
Year 20[ ]
Year 20[ ]
1.2.a Provide the following information on your firm for the three most recent years:
20[ ]
20[ ]
20[ ]
| a. | Number of lost workday cases. |
| b. | Number of restricted workday cases. |
| c. | Number of cases with medical attention only. |
| d. | Number of fatalities. |
| e. | 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[ ]
20[ ]
| a. | Number of lost workday cases. |
| b. | Number of restricted workday cases. |
| c. | Number of cases with medical attention only. |
| d. | Number of fatalities. |
| e. | Number of hours worked. |
2. Are accident reports and report summaries sent to the following and how often?
| No |
| Yes |
| Monthly |
| Quarterly |
| Annually |
| a. | Project Superintendent/Site Manager. |
| |_| | |
| |_| | |
| |_| | |
| |_| | |
| |_| |
| b. | Vice President/Manager of Construction |
| |_| | |
| |_| | |
| |_| | |
| |_| | |
| |_| |
| c. | Safety Director |
| |_| | |
| |_| | |
| |_| | |
| |_| | |
| |_| |
| d. | President of Firm |
| |_| | |
| |_| | |
| |_| | |
| |_| | |
| |_| |
3. Do you hold site safety meetings for field employees both Manual and Non-Manual?
| Yes |
| |_| |
| No |
| |_| |
How Often?
| Weekly |
| |_| |
| Bi-Weekly |
| |_| |
| Monthly |
| |_| |
| Less Often, As needed |
| |_| |
4. Do you conduct project safety inspections?
| Yes |
| |_| |
| No |
| |_| |
If yes, who conducts this inspection?
| TITLE |
| HOW OFTEN? |
5. How are accident records and accident summaries kept? How often are they reported?
| No |
| Yes |
| Monthly |
| Annually |
a. Accidents totaled for the entire company
| |_| |
| |_| |
| |_| |
| |_| |
b. Accidents totaled by project
| |_| |
| |_| |
| |_| |
| |_| |
(1) Subtotaled by superintendent
| |_| |
| |_| |
| |_| |
| |_| |
(2) Subtotaled by foreman
| |_| |
| |_| |
| |_| |
| |_| |
6. How are costs of individual accidents kept? How often are they reported?
| No |
| Yes |
| Monthly |
| Annually |
a. Costs totaled for the entire company
| |_| |
| |_| |
| |_| |
| |_| |
b. Costs totaled by project
| |_| |
| |_| |
| |_| |
| |_| |
(1) Subtotaled by superintendent
| |_| |
| |_| |
| |_| |
| |_| |
(2) Subtotaled by foreman
| |_| |
| |_| |
| |_| |
| |_| |
7. 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 |
8. Do you have a written safety & health program?
| Yes |
| |_| |
| No |
| |_| |
9. Do you have an orientation program for new hires?
| Yes |
| |_| |
| No |
| |_| |
If yes, submit a copy for evaluation. Does it include instruction on the following?
| Yes |
| No |
| Yes |
| No |
| a. | Head protection |
| |_| | |
| |_| | |
| i. | Fire protection |
| |_| | |
| |_| |
| b. | Eye protection |
| |_| | |
| |_| | |
| j. | First aid facilities |
| |_| | |
| |_| |
| c. | Hearing protection |
| |_| | |
| |_| | |
| k. | Emergency procedures |
| |_| | |
| |_| |
| d. | Respiratory protection |
| |_| | |
| |_| | |
| l. | Toxic substances |
| |_| | |
| |_| |
| e. | Safety belts and lifeline |
| |_| | |
| |_| | |
| m. | Trenching and excavation |
| |_| | |
| |_| |
| f. | Scaffolding |
| |_| | |
| |_| | |
| n. | Signs, barricades, flagging |
| |_| | |
| |_| |
| g. | Perimeter guarding |
| |_| | |
| |_| | |
| o. | Electrical safety |
| |_| | |
| |_| |
| h. | Housekeeping |
| |_| | |
| |_| | |
| p. | Rigging and crane safety |
| |_| | |
| |_| |
| |_| | |
| |_| | |
| q. | Road Safety (Driving) |
| |_| | |
| |_| |
10. Do you have a program for newly hired or promoted foremen?
| Yes |
| |_| |
| No |
| |_| |
If yes, submit a copy for evaluation. Does it include the following?
| Yes |
| No |
| Yes |
| No |
| a. | Safe work practices |
| |_| | |
| |_| | |
| e. | First aid procedures |
| |_| | |
| |_| |
| b. | Safety supervision |
| |_| | |
| |_| | |
| f. | Accident investigation |
| |_| | |
| |_| |
| c. | Toolbox meetings |
| |_| | |
| |_| | |
| g. | Fire protection and prevention |
| |_| | |
| |_| |
| d. | Emergency procedures |
| |_| | |
| |_| | |
| h. | New worker orientation |
| |_| | |
| |_| |
11. Do you hold craft “toolbox” safety meetings?
| Yes |
| |_| |
| No |
| |_| |
How Often?
| Weekly |
| |_| |
| Bi-Weekly |
| |_| |
| Monthly |
| |_| |
| Less Often, As needed |
| |_| |
12. Do you have a written Hazard Communication program?
| Yes |
| |_| |
| No |
| |_| |
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 |
| |_| |
| No |
| |_| |
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.
| a. |
| b. |
| c. |
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