Appendix D - Subcontractor Safety and Quality Assurance Program Review.pdf

Form 10200.140 Rev 3, 09/08/2025 1

SUBCONTRACTOR SAFETY & QUALITY ASSURANCE

PROGRAM REVIEW

Contract #

Project Name

Subcontractor

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

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 (e.g., 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 Signature

Identify your Worker's Compensation carrier:

Address:

Phone:

Rev 3, 09/08/2025 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:

Name/Title: 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 3, 09/08/2025 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 PROGRAM

Ames National Laboratory Quality Assurance has reviewed the subcontractor’s Quality Assurance program, if applicable, and made the determination:

1. Subcontractor has a documented Quality Assurance Program that adequately addresses quality requirements applicable to the work to be performed (1 is required for Level III Activities).

2. Subcontractor currently does not have a documented Quality Assurance Program, but has reviewed and committed to performing work in accordance with the Ames National Laboratory Quality Assurance Program Plan (Either 1 or 2 is required for Level II Activities).

3. Subcontractor currently does not have an adequately documented Quality Assurance Program and has not committed to performing work in accordance with the Ames National Laboratory Quality Assurance Program Plan (Either 1 or 2 is required for Level II Activities).

QA Signature Date

Rev 3, 11/01/2024

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

Rev 3, 11/01/2024

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

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