ANL-1344-H Contractor Safety Questionnaire (3-17-2025).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 1.0 or less 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.

Identify your Worker’s Compensation carrier:

Year

EMR

Year

EMR

Year

EMR

Year

Year

Year

2a. Provide OSHA Recordable and DART (Days Away, Restricted, or Transferred) Rates for the last 3 years:

OSHA Recordable Rate:

Year:

Year:

Year:

DART Rate Year:

Year:

Year:

Example of tool to use to calculate DART rate https://www.omnicalculator.com/finance/dart-rate

2b. Provide OSHA, EPA and/or DOE Citation history for last 3 years.

If there is a citation, please provide brief description of citation & company corrective actions.

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 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

Radiological Safety/Awareness Provide an example of proof of orientation (i.e. sign-in sheet, certificate, etc.)

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

|_| Yes

|_| No

QUALITY ASSURANCE

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

2. 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____________________________

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

4. |_||_| Have you conducted work at a National Laboratory? Yes No

a. Name of the National Laboratory:

b. Contract Scope Details:

c. Estimated Current Value:

d. Any Safety Concerns:

e. National Laboratory Technical Contact Name, Email, & Telephone Number 5.

Associated document: xxxxxx ANL-1344H (xx/xx/2024) Page 2 of 3

Associated document: xxxxxx ANL-1344H (xx/xx/2024) Page 1 of 2 image1.jpeg