Appendix E - Contractor Safety and Quality Assurance Questionnaire.docx
DOCX document 358 KB Posted
- Attached to
- Gas Cylinders & Liquid Nitrogen/Helium
- Solicitation number
- RFP-A27-0308
- Issued by
-
Department of Energy Ames Laboratory
About this file
This is an Appendix containing a Contractor Safety and Quality Assurance Questionnaire template used to evaluate contractor qualifications for Ames Laboratory construction and service contracts.
The questionnaire is divided into two main sections: Safety and Quality Assurance. The Safety section requires contractors to provide three years of historical data on Experience Modification Rates (EMR) from their Worker's Compensation carrier, OSHA 300 log information including recordable cases, lost workday cases, fatalities, and employee hours worked, and details on accident reporting frequency to management. Contractors must also document the existence of written safety policies, hazard communication programs, and identify their safety program manager. The form assesses the frequency of site safety meetings, craft toolbox meetings, and safety inspections, and requires documentation of new hire orientation programs covering 15 specific safety topics ranging from personal protective equipment to emergency procedures. Additionally, contractors must describe programs for newly hired or promoted foremen that include safe work practices, safety supervision methods, and accident investigation procedures. The Quality Assurance section categorizes contractors into four levels based on whether they maintain documented quality assurance programs and prior experience performing work at Ames Laboratory, with Level 1 and Level 2 contractors required to submit copies of their Quality Assurance Manuals. The form includes an extensive checklist of construction work categories organized by trade (site work, concrete, metals, roofing, doors/windows, finishes, mechanical, electrical, etc.), with columns indicating whether work will be performed by the contractor or subcontractors. This questionnaire serves as an evaluation tool rather than a solicitation for specific products or services.
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CONTRACTOR SAFETY & QUALITY ASSURANCE
QUESTIONNAIRE
Contract #
Approved
Approved as noted
Not approved – Resubmit
ESH Signature
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. |
Identify your Worker's Compensation carrier:
Address:
Phone:
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 | |||
| (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 |
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 | |_| | |_| |
| 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.
Form #10200.140
ESH&A, 4-9769
Rev 1.2, Effective Date 10-15-12 Form 10200.140
ESH, 4-9769
Rev 1.3, 04/01/2017 1
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
PFS-525 (8-01) Page 1 of 3 Form 10200.140
ESH
| Rev 2, 04/29/2022 | 5 | |
| 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
| |_| |_| | General |
| |_| |_| | 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
| |_| |_| | General |
| |_| |_| | Substations |
| |_| |_| | Primary Distribution |
| |_| |_| | Secondary Distribution |
| |_| |_| | Lighting |
| |_| |_| | Cathodic Protection |
| |_| |_| | Controls |
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