B2.07.03_DRAFT-Sec_J_Attachment_03_IIPP_Form.pdf

27 May 2026 SLAC-I-730-0A21J-032-R002 1 of 1

ENVIRONMENT, SAFETY & HEALTH DIVISION

Chapter 42: Subcontractor Safety Injury and Illness Prevention Plan Acknowledgement Form Product ID: 509 | Revision ID: 2865 | Date Published: 27 May 2026 | Date Effective: 27 May 2026 URL: https://www-esh.slac.stanford.edu/eshmanual/references/subcontractorFormIIPP.pdf

This form is used for documenting subcontractor acknowledgement of injury and illness prevention program requirements and capturing occupational medicine information. The form is required for both green and non-green work. Procurement maintains the completed form for the awarded subcontractor. (See Subcontractor Safety: Green Work Procedure [SLAC-I-730-0A21C-025] and Subcontractor Safety: Non-green Work Procedure

[SLAC-I-730-0A21C-024].)

1. Prime subcontractors must flow these requirements down to sub-tier subcontractors they hire.

2. All subcontractors, prime and sub-tier, must complete a separate form.

3. The form must be completed by an authorized representative of the subcontractor, preferably the supervisor / foreman for the job.

4. Submission of this completed form with the proposal is a prerequisite for issuance of the notice to proceed.

Project name

Company name

Superintendent / foreman

Name Phone E-mail

Point of contact

Name Phone E-mail

1 Injury and Illness Prevention Program Compliance While their workers are physically located at SLAC, subcontractors to SLAC must comply with the requirements of the Department of Energy (DOE) Worker Safety and Health Program (10 CFR 851). These requirements are more stringent in some areas than Cal/OSHA IIPP requirements (8 CCR 1509 and 8 CCR 3203). (See Subcontractor Safety: Additional IIPP Requirements [SLAC-I-730-0A21S-062] for the differences.)

Subcontractors have the option to adopt SLAC’s 851-compliant IIPP or to submit their own 851-compliant IIPP to SLAC for review and approval.

This information is provided only as a guide: it is your responsibility to ensure you have read and understood the regulatory requirements.

I certify that that I have read the requirements of the SLAC IIPP and attest that

Our work on this subcontract will comply with the requirements of the SLAC IIPP, or We have developed an IIPP that is as protective as the SLAC IIPP (attach)

Prepared by (foreman / supervisor for the job if possible)

Name Signature Date

2 Occupational Medicine Will you have any employees who will work on site at SLAC for 30, 8-hour days in a 12-month period, or who are enrolled for any length of time in a medical or exposure monitoring program required by federal, state, or local regulations (for example, hearing conservation, respiratory protection, lead exposure, or beryllium exposure)? No Yes If yes, you must

1. Have comprehensive occupational medicine services for your workers and comply with the occupational medicine requirements of the SLAC

IIPP.

2. Provide your occupational medicine provider (clinic / physician) contact information:

Name Phone E-mail

Energy Employees’ Occupational Illness Compensation Program Act (EEOICPA) and Former Worker Medical Screening Program (FWP) Information Dissemination: Participants seeking information on potential compensation, visit the FWP website.

https://esh.slac.stanford.edu/general/subcontractor/ https://www-internal.slac.stanford.edu/esh/docreview/reports/revisions.asp?ProductID=509 https://www-esh.slac.stanford.edu/eshmanual/references/subcontractorFormIIPP.pdf https://www-esh.slac.stanford.edu/eshmanual/references/subcontractorProcedGreen.pdf https://www-esh.slac.stanford.edu/eshmanual/references/subcontractorProcedNonGreen.pdf https://www.ecfr.gov/current/title-10/chapter-III/part-851 https://www.dir.ca.gov/Title8/1509.html https://www.dir.ca.gov/Title8/1509.html https://www.dir.ca.gov/Title8/3203.html https://www-esh.slac.stanford.edu/eshmanual/references/subcontractorReqIIPP.pdf https://esh.slac.stanford.edu/iipp https://www.energy.gov/ehss/former-worker-medical-screening-program-0