Appendix D - Ames Laboratory Contractor Safety and Quality Assurance Information Questionnaire.pdf

Form 10200.140

ESH&A, 4-9769

Rev 1.3, 04/01/2017 1

APPENDIX D - AMES LABORATORY

CONTRACTOR SAFETY & QUALITY ASSURANCE

INFORMATION QUESTIONNAIRE

RFP #

Project Name

Contractor

Address

Phone Contact # Email

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.

Year Identify your Worker's Compensation carrier:

Year

Year

Address:

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

(i.e., 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:

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

ESH&A

Signature

Approved Approved as noted Not approved – Resubmit

Rev 1.3, 04/01/2017 2

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

Never Monthly Quarterly Annually

Field Superintendent Vice President of Construction President/CEO

4. Does your firm:

Have a written company safety policy signed by a company officer?

Have an established written safety plan?

Have a written Hazard Communication Program?

Yes No 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?

7.

8. How often do you conduct safety inspections?

Who performs this inspection?

9. Do you have orientation for new hires?

If yes, does it include:

Head Protection Eye Protection Hearing Protection Respiratory Protection Safety Belt and Lifeline (Fall Protection)

Scaffolding/Work Platform, Competent Person Perimeter Guarding/Floor, Wall and Roof Openings Housekeeping Fire Protection First-Aid Emergency Procedures – Rescue/Evacuation Toxic Substances Trenching and Excavation, Competent Person Signs, Barricades, Flagging Electrical Safety, Lockout/Tagout Procedures Rigging and Crane Safety Hazard Recognition

Weekly Monthly Never Bi-Weekly As Required

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

Weekly Monthly Never Bi-Weekly As Required

Rev 1.3, 04/01/2017 3

10. Do you have a program for newly hired/promoted foremen? Yes No

If yes, does it include:

Safe Work Practices

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

QUALITY ASSURANCE

Check one of the following boxes:

LEVEL 1

Contractor has a documented quality assurance program.

LEVEL 2

Contractor has a documented Quality Assurance Program that adequately addressed the quality requirements applying to work normally performed.

LEVEL 3

Contractor currently does not have a documented Quality Assurance Program, but has successfully performed construction activities at the Ames Laboratory.

LEVEL 4

Contractor currently does not have a documented Quality Assurance Program, and has not previously performed construction activities at the Ames Laboratory.

If you check the block in either 1 or 2 above, please enclose a copy of your Quality Assurance Manual.

Rev 1.3, 04/01/2017

Check all blocks that apply to this contract:

(1) Work to be performed by your Company

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

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

Demolition Waterproofing Cabinets and Casework Earthwork Insulation Window Treatment Site Improvements Fireproofing Furniture and Accessories Landscaping Preformed Siding Paving and Surfacing Flashing and Sheet Metal Special Construction

Roofing (General) Concrete Shingles and Roofing Tiles Clean Rooms

Preformed Roofing Insulated Rooms Cast-in Place Concrete Membrane Roofing Radiation Protection Precast Concrete Pre-engineered Structures Cementitious Decks Doors and Windows Liquid and Gas Storage Tanks Restoration and Cleaning Industrial/Process Control Systems

Metal Doors and Frames Fire Suppression/Supervisory Systems Masonry Wood and Plastic Doors

Special Doors Mechanical Unit Masonry Entrances and Store Fronts Stone Metal Windows General Restoration Wood and Plastic Windows Insulation

Special Windows Special Process Piping Systems Metals Hardware and Specialties Plumbing and Sewerage

Glazing Fire Protection General Power or Heat Generation Structural Metal Framing Finishes Air Distribution Joists Decking Miscellaneous and Ornamental

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

Controls and Instrumentation

Rev 1.3, 04/01/2017

1 2 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

1 2 Equipment

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

1 2 Electrical

General Substations Primary Distribution Secondary Distribution Lighting Cathodic Protection Controls

(1) Work to be performed by your Company