Contractor Safety Information Questionnaire.pdf

PFS-525 (8-05)

ARGONNE NATIONAL LABORATORY

CONTRACTOR SAFETY INFORMATION QUESTIONNAIRE

Contract #

Project Name

Contractor

Address

Phone Contact # Fax #

1. List your firm's interstate experience modification rate for the past three consecutive years.

NOTE: This information can be obtained from your Worker's Compensation carrier.

Identify your Worker’s Compensation carrier:

Year

Year Address:

Year Phone:

2. Using the information from the OSHA No. 300 log, provide the following information on injuries and illnesses for the past three consecutive years.

Year Year Year

A. Total number of recordable cases (Sutures, fractures, burns, rashes, foreign body in eye, etc.) including cases involving lost time.

B. Number of lost workday cases.

C. Number of lost workdays

D. Number of fatalities.

E. Employee hours worked each year.

Rate Calculation Formulas: To be completed by Contractor

A) Number of OSHA Recordable Cases x 200,000 Number of Hours Worked Per Year

B) Number of Lost Time Accidents x 200,000 Number of Hours Worked Per Year

C) Number of Days Lost x 200,000 Number of Days Worked Per Year

3. How often are accident reports (OSHA 300) and report summaries sent to the following:

4. Does your firm:

Have a written company safety policy signed by a company officer? Yes No Have an established written safety plan? Yes No Have a written Hazard Communication Program? Yes No

5. Identify by name and title the person within your firm directly responsible for your firm's safety program: Phone:

6. How often do you hold site safety meetings for field supervisors?

Weekly Monthly Never Bi-Weekly As Required

7. How often do you hold craft “tool box” safety meetings?

Weekly Monthly Never Bi-Weekly As Required

8. How often do you conduct safety inspections?

Who performs this inspection?

9. Do you have orientation for new hires? Yes No If yes, does it include:

Head Protection Eye Protection Hearing Protection Respiratory Protection Safety Belt and Lifeline Scaffolding/Work Platform, Competent Person Training Required

Perimeter Guarding/Floor, Wall and Roof Openings Housekeeping Fire Protection First-Aid Facilities Emergency Procedures – Rescue/Evacuation Toxic Substances Trenching and Excavation, Competent Person Training Required

Signs, Barricades, Flagging Electrical Safety, Lockout/Tagout Procedures Rigging and Crane Safety Hazard Recognition

Yes No

Never Monthly Quarterly Annually

Field Superintendent Vice President of Construction

President/CEO

10. Do you have a program for newly hired/promoted foremen? Yes No If yes, does in include:

Safe Work Practice ------------------------------------------------------------------- Methods of Safety Supervision ----------------------------------------------------- Toolbox Meetings--------------------------------------------------------------------- Emergency Procedures --------------------------------------------------------------- First-Aid Facilities -------------------------------------------------------------------- Accident Investigation --------------------------------------------------------------- Fire Protection and Prevention ------------------------------------------------------ New Worker Orientation ------------------------------------------------------------

Yes No

(1) Work to be performed by your Company

(2) Work to be performed by a Sub-Contractor to your Company

Check all blocks that apply to this contract:

1 2 Site Work 1 2 Thermal and Moisture Protect 1 2 Furnishings

Demolition Earthwork Tunneling Piling, Caissons and Cofferdams Site Improvements Landscaping Paving and Surfacing Ponds and Reservoirs Railroad Work

Concrete

Cast-in Place Concrete Precast Concrete Cementitious Decks Restoration and Cleaning

Masonry

Unit Masonry Stone Restoration

Metals

General Structural Metal Framing Joists Decking Miscellaneous and Ornamental

Wood and Plastics

Rough Carpentry Heavy Timber Construction Prefabricated Structural Wood Finish Carpentry Architectural Woodwork

Conveying Systems

Elevators Hoists and Cranes Lifts Material Handling Systems

Waterproofing and Damproofing Insulation Fireproofing Preformed Siding Flashing and Sheetmetal Roofing (General) Shingles and Roofing Tiles Preformed Roofing Membrane Roofing

Doors and Windows

Metal Doors and Frames Wood and Plastic Doors Special Doors Entrances and Store Fronts Metal Windows Wood and Plastic Windows Special Windows Hardware and Specialties Glazing

Finishes

Lath and Plaster/Drywall Tile/Terrazzo Acoustical Treatment Wood Flooring Stone and Brick Flooring Resilient Flooring Carpeting Painting Wall Covering

Equipment

Waste Handling Equipment Water Supply and Treatment Equipment Communication Systems Fluid Waste Disposal and Treatment Equipment Laboratory Equipment

Cabinets and Casework Window Treatment Furniture and Accessories

Special Construction

Clean Rooms Insulated Rooms Radiation Protection Pre-engineered Structures Vaults Liquid and Gas Storage Tanks Industrial/Process Control Systems Fire Suppression/Supervisory Systems Cooling Towers

Mechanical

General Insulation Special Process Piping Systems Plumbing and Sewerage Fire Protection Power or Heat Generation Air Distribution Controls and Instrumentation

Electrical

General Substations Primary Distribution Secondary Distribution Lighting Cathodic Protection Controls