ANL 1344 Contractor Safety Questionnaire.docx

ARGONNE NATIONAL LABORATORY

CONTRACTOR SAFETY AND QUALITY INFORMATION QUESTIONNAIRE – NON-CONSTRUCTION SERVICES

|_| Reviewed

|_| Reviewed as noted

|_| Not Approved - Resubmit

Provide any other legal business used in the past three (3) years:

INSTRUCTIONS

Please provide the below information as applicable to your company and provide the information for any proposed subcontractors as well.

1. List your firm's interstate experience modification rate (“EMR”) for the past three consecutive years.

NOTE: This information can be obtained from your Worker's Compensation carrier and should be provided within your policy The Laboratory’s expectation is that Contractor and Contractor’s subcontractors have an EMR of <1 and if EMR exceeds this number, the Laboratory reserves the right to conduct further inquiries on safety history or require Contractor to conduct such inquiries on its subcontractors. Applies to all companies you have done business within the past.

Identify your Worker’s Compensation carrier:

Year

Year

Year

Year

Year

Year

3. Does your firm:

Have a written company safety policy signed by a company officer? |_| Yes |_| No

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

If yes, does it include (if applicable):

All Applicable Personal Protective Equipment Fall Protection

Scaffolding/Work Platform, Competent Person Training Required

Perimeter Guarding/Floor, Wall and Roof Openings

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

Radiological Safety/Awareness

6. Do you have personnel with OSHA 10 hour or greater certification who will serve as ES&H representative?

|_| Yes

|_| No

7. Please describe any other safety programs and certifications your firm has in place (e.g. medical certification and qualification including respiratory protection, electrical safety, visual acuity for equipment operation, forklift certification, etc.):

QUALITY ASSURANCE

8. Does your company have a documented quality assurance program? |_| Yes |_| No If yes, please enclose a copy of your Quality Assurance Manual.

9. Do your employees have non-safety related documented up to date certifications (relevant to job) |_| Yes |_| No Check yes for all applicable certifications NQA-1 |_| Yes |_| No Universal Type I Certification |_| Yes |_| No Other |_| Yes |_| No If yes, please list relevant certifications____________________________

10. Are you aware of any non-conformances or Supplier Corrective Action Requests (SCAR) issued from ANL? |_| Yes |_| No Check yes, please explain….

11. Have you conducted work at Argonne National Laboratory? |_| Yes |_| No

image1.jpeg