Appendix D - 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

Year

Year

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

Approved

Approved as noted

Not approved – Resubmit

ESH&A

Signature

Identify your Worker's Compensation carrier:

Address:

Phone:

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? 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:

Yes No

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

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:

Yes No

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

Demolition

Earthwork

Site Improvements

Landscaping

Paving and Surfacing

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

1 2 Thermal and Moisture Protection

Waterproofing

Insulation

Fireproofing

Preformed Siding

Flashing and Sheet Metal

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

Acoustical Treatment

Wood Flooring

Stone and Brick Flooring

Resilient Flooring

Carpeting

Painting

Wall Covering

1 2 Furnishings

Cabinets and Casework

Window Treatment

Furniture and Accessories

Special Construction

Clean Rooms

Insulated Rooms

Radiation Protection

Pre-engineered Structures

Liquid and Gas Storage Tanks

Industrial/Process Control Systems

Fire Suppression/Supervisory Systems

Mechanical

Insulation

Special Process Piping Systems

Plumbing and Sewerage

Fire Protection

Power or Heat Generation

Air Distribution

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

Substations

Primary Distribution

Secondary Distribution

Lighting

Cathodic Protection

Controls