Attach 6 - Safety Program Performance Questionnaire.docx

SAFETY PROGRAM PERFORMANCE QUESTIONNAIRE

October 6, 2023 Contractors shall complete this form and include it as an attachment to Volume I – Technical Proposal. The information provided on this form will be reviewed as part of the Solicitation. Please provide the requested information as complete as possible to facilitate our full review and evaluation.

Name of Contractor: _________________________________________________________ Address of Contractor: _________________________________________________________ Contact Name: _________________________________________________________ Phone Number: ________________________ Date submitted: _______________________ Standard Industrial Classification (SIC) or North American Industry Classification System (NAICS) Code(s): _____________________________________________________________________________

1. Has your company worked for AOC in the last 5 years? _____Yes _____ No If yes, what year(s) and what project manager(s)? ______________________________________________________

SAFETY

2. Use your OSHA 300/300A logs to record the number of injuries and illnesses for the last five years. Please note that AOC requires all contractors to provide incident statistics, even though certain companies may not be statutorily required to keep OSHA 300/300A logs.

Attach a copy of your OSHA 300 logs for the last five years

* Lost Work Day Incident Rate = Number of Lost Work Day Cases x 200,000 Number of Hours Worked ** OSHA Recordable Incident Rate: = Number of OSHA Recordable Cases x 200,000 Number of Hours Worked

3. Enter your company’s Worker’s Compensation (WC) Experience Modification Rate (EMR) for the five (5) most recent years:

f. Submit with questionnaire a letter from your WC insurance carrier certifying the above EMRs rates.

g. If your WC carrier has not issued your company an EMR because you have not accrued enough WC costs, provide a copy of your WC Loss Run (available from your WC carrier).

h. If your current EMR is greater than 1.0, provide a written explanation of the safety procedures, programs, and training implemented by your company to reduce this rate.

4. List activities your company will be performing on AOC projects and the anticipated hazardous work operations (For example: excavation work, fall protection, ladders, scaffolding, confined space work, heavy equipment etc.)

Activities: _________________________________________________________________________________ HazOps: _________________________________________________________________________________

a. Will you subcontract work activities to other contractors? Yes _____ No _____ If yes, please detail what portion of work: ________________________________________________________________________________________

b. Do you prequalify subcontractors? Yes __ No __ if yes, please attach procedure used to qualify subcontractors.

5. Has your company received an OSHA (Federal or State) citation within the last five (5) years? Yes ____ No ____ If yes, provide copies of the citation(s) and provide the following information below:

a. The number and type of Violations___________________________________________________________________________________

b. The penalties assessed by OSHA______________________________________________________________________________________

c. Were the citations contested/vacated?___________________________________________________________________________

d. What specific corrective actions were taken to prevent further penalties/injuries? ______________________________________________________________________________________________________________________________________________________________________________________

6. Does your company have a written occupational safety and health program?

Yes ____ No ____ if yes, please provide a copy of your health & safety program.

7. Does your company conduct field safety inspections to determine compliance with applicable regulations, contractual requirements and procedures?

9. Does your company have a program in place to discipline workers that perform unsafe work practices?

Yes ____ No ____ If yes, please provide as attachment.

10. Does your company have written Accident Investigation Procedures?

Yes _____ No _____ If yes, please provide a copy of procedures.

11. Does your company currently maintain a program in compliance with applicable state “Right to Know” laws and the OSHA Hazard Communication Standard? Yes ___ No ___ if yes, please provide a copy of program documentation.

12. Does your company currently maintain an Accident Prevention Program in compliance with applicable federal and state OSHA Regulations? Yes ___ No ___ N/A ___ if yes, please provide a copy of program documentation.

13. Does your company implement a medical surveillance program for employees that work on hazardous waste sites or with hazardous chemicals (i.e., lead, asbestos, benzene, arsenic, formaldehyde, etc.)? Yes ___ No ___ N/A ___

CERTIFICATION

The undersigned warrants and represents the data provided in this document is accurate in all respects.