Attach 7 - Step 2 Safety and Enviro PPQ.docx
DOCX document 29 KB Posted
- Attached to
- AOC MACC Onboarding Federal contract opportunity
- Solicitation number
- AOCACB25R0006
- Issued by
- Architect of the Capitol
About this file
This is a Safety and Environment Program Performance Questionnaire that contractors must complete and submit to the Architect of the Capitol (AOC) as part of Step 2 of the solicitation evaluation process. The questionnaire requires detailed information about a contractor's safety record and environmental compliance history over the past 3-5 years.
The form requires contractors to provide their OSHA incident statistics (fatalities, lost work day rates, recordable incident rates), Workers' Compensation Experience Modification Rates, safety training programs, written safety procedures, accident investigation protocols, and environmental compliance records. Key requirements include submission of OSHA 300/300A logs, documentation of safety training programs, environmental management systems, hazardous materials handling procedures, and certification of substance abuse testing programs. The questionnaire must be reviewed and approved by AOC's Health and Safety Manager and Environmental Manager before a contractor can be accepted into the program.
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Text version
SAFETY AND ENVIRONMENT PROGRAM PERFORMANCE QUESTIONNAIRE
Contractors shall complete this form and submit it to John Lingamfelter by email at john.lingamfelter@aoc.gov, and copy Matthew Hutcherson at matthew.hutcherson@aoc.gov. The information provided on this form will be reviewed as part Step 2 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 3 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 three 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.
| YEAR | Current: | _________ | __________ | _________ | _________ | ||
| a. Number of Fatalities | _________ | _________ | _________ | _________ | |||
| b. Lost Work Day Incident Rate* | _________ | _________ | _________ | ||||
| c. OSHA Recordable Incident Rate** | _________ | _________ | _________ | ||||
| d. Number of Hours Worked | _________ | _________ | _________ | ||||
| e. Total Number of Employees on Your Payroll | _________ | _________ | _________ |
Attach a copy of your OSHA 300 logs for the last three 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 three (3) most recent years:
| Year | Interstate | Intrastate | ||
| a. | _______ | _________ | _________ | |
| b. | _______ | _________ | _________ | |
| c. | _______ | _________ | _________ |
d. Submit with questionnaire a letter from your WC insurance carrier certifying the above EMRs rates.
e. 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).
f. 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?
| a. | Yes ____ | No ____ | if yes, please provide sample copy of inspection form. |
| b. Who conducts these inspections? (Please provide position/title) | ____________________________________________________________________________________ | ||
| c. How often are safety inspections conducted? | ____________________________________________________________________________________ |
8. Does your company have the following on your staff or on retainer?
| No | Yes | How Many | Staff | Retainer | certification number(s) | |||||
| Occupational Physician | ___ | ___ | ____ | ____ | _____ | ________ _______________________ | ||||
| Certified Industrial Hygienist | ___ | ___ | ____ | ____ | _____ | ________ _______________________ | ||||
| Certified Safety Professional | ___ | ___ | ____ | ____ | _____ | ________ _______________________ | ||||
| Certified Health Physicist | ___ | ___ | ____ | ____ | _____ | ________ _______________________ | ||||
| 9. Does your company have an orientation program for new hires? | Yes ___ | No ___ | ||||||||
| If yes, please provide an outline of the orientation and the topics covered. |
10. Has your company implemented any of the following training programs? If yes, provide last date training was provided. Documented training records may be required prior to start of work or at the discretion of AOC.
| Yes | No | Date | Yes | No | Date | ||||
| ___ | ___ | _______ Asbestos | ___ | ___ | ______ Hazardous Waste (40-hour) | ||||
| ___ | ___ | _______ Blasting/Explosives | ___ | ___ | _______ Hearing Conservation | ||||
| ___ | ___ | _______ Bloodborne Pathogens | ___ | ___ | _______ Heavy Equipment operation | ||||
| ___ | ___ | _______ Confined Space Entry | ___ | ___ | _______ Laboratory Safety | ||||
| ___ | ___ | _______ OSHA Certified 10 Hours | ___ | ___ | _______ Ladder/Scaffolding | ||||
| ___ | ___ | _______ OSHA Certified 30 Hours | ___ | ___ | _______ Lead | ||||
| ___ | ___ | _______ Cranes Operations | ___ | ___ | _______ Lockout/Tagout | ||||
| ___ | ___ | _______ Electrical Safety | ___ | ___ | _______ PPE | ||||
| ___ | ___ | _______ Excavation Competent Person | ___ | ___ | _______ Powder-actuated Tools | ||||
| ___ | ___ | ______ _Fall Protection | ___ | ___ | _______ Process Safety Management | ||||
| ___ | ___ | _______ Fire Extinguishers | ___ | ___ | _______ Radiation Protection | ||||
| ___ | ___ | _______ First Aid/CPR | ___ | ___ | _______ Respiratory Protection | ||||
| ___ | ___ | _______ Forklift Operations | ___ | ___ | _______ Welding/Cutting |
Who conducts training for your company (name(s), title(s))? __________________________________________________________________________________________________
11. Does your company have a program in place to discipline workers that perform unsafe work practices?
Yes ____ No ____ If yes, please provide as attachment.
12. Does your company have written Accident Investigation Procedures?
Yes _____ No _____ If yes, please provide a copy of procedures.
13. 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.
14. 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.
15. 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 ___
| If yes, please provide copy of program documentation. | |||||
| 16. Does your company hold “tailgate/toolbox” safety meetings? | Yes ___ | No ___ | |||
| If yes, how often? __________________________________________ please provide sample copy(s) | |||||
| 17. Does your company have a written Alcohol and Substance Abuse Program? | Yes ___ | No ___ | |||
| If yes, please provide program as attachment. |
If yes, does it include the following?
| a. 5-panel substance testing? | Yes ___ | No ___ | |||||
| b. Pre-employment/pre-job assignment testing (within 30 days of pre-job assignment)? | Yes ___ | No ___ | |||||
| c. Post-accident drug and alcohol testing? | Yes ___ | No ___ | |||||
| d. Random testing (5 percent per month)? | Yes ___ | No ___ | |||||
| e. Reasonable suspicion drug and alcohol testing? | Yes ___ | No ___ |
ENVIRONMENT
18. Does your company have a written environmental program? Yes ____ No ____ If yes, please provide a copy.
| 19. Does your company implement an Environmental Management System? | Yes ____ No ____ |
| 20. Has your company received an EPA/State violation in the last 5 years? | Yes ____ No ____ |
If yes, provide:
a. Number and type of violation(s): ___________________________________________________________________________________
b. Penalties: ___________________________________________________________________________________
c. Corrective actions: ___________________________________________________________________________________
21. Has your company reported any spills in the last 3 years? Yes ____ No ____ If yes, please provide information:
22. If your company will be transporting hazardous materials or waste, please provide the following:
| a. | Transport Method: | ___ Air | ___ Highway | ___ Rail | ___Vessel |
| b. | Transporter ID No(s): ___________________________________________________________________ | ||||
| c. | Motor Carrier Nos.: | USDOT_________________ | State _________________ | ||
| d. | Motor Carrier Safety Rating: | USDOT _________________ | State _________________ | ||
| e. | EPA/State ID No(s): ___________________________________________________________________ |
23. If your company will be disposing of hazardous waste, please provide the following:
a. Facility Name and Address: _______________________________________________________________________________
| b. | Services (e.g., hazardous waste, asbestos, PCBs, recycling) _______________________________________________________________________________ | |
| c. | Attach proof (e.g., copy of front page) of all Federal, State and local permits or licenses. | |
| d. | Is the facility approved under the CERCLA Off-Site Rule? | • Yes • No |
CERTIFICATION
The undersigned warrants and represents the data provided in this document is accurate in all respects.
| Name of Firm: | ________________________________________________________________________ | |
| Completed by: | ________________________________________________________________________ | |
| Signature: | ________________________________________________________________________ | |
| Title: | ________________________________________________________________________ | |
| Date: | ______________ |
AOC USE ONLY
CO Review Reviewed by: _____________________________________________________________ Date: _________________ All required data present prior to sending to HSE: Yes ____ No ____ If no, please gather data from contractor prior to sending to HSE for approval.
Responsible Health and Safety Manager Review Reviewed by: _____________________________________________________________ Date: _________________ Accepted Conditional* Rejected Responsible Environmental Manager Review (when reviewed by REM) Reviewed by: _____________________________________________________________ Date: _________________ Accepted Conditional* Rejected PMD Lead (for criteria exceptions only) Reviewed by: _____________________________________________________________ Date: _________________ Accepted Conditional* Rejected *A Corrective Action Plan is required if standard criteria is not met
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