B2.07.05_DRAFT-Sec_J_Attachment_05_SQF.pdf

21 May 2021 SLAC-I-730-0A21J-027-R010 1 of 5

ENVIRONMENT, SAFETY & HEALTH DIVISION

Chapter 42: Subcontractor Safety Subcontractor Safety Qualification Form Product ID: 456 | Revision ID: 2364 | Date Published: 21 May 2021 | Date Effective: 21 May 2021 URL: https://www-group.slac.stanford.edu/esh/eshmanual/references/subcontractorFormSQF.pdf

This form applies to prime subcontractors (those directly contracted to SLAC)1, performing construction work2 or high-risk service work3 (see Subcontractor Safety: Non-green Work Procedure [SLAC-I-730-0A21C-024]).

The safety qualification is valid for (a) one year and (b) the type of work listed below. Please fill out this form completely. Do not leave items blank and provide all required supporting documents. SLAC reserves the right to accept or reject any directly-contracted subcontractor based on the qualification criteria. SLAC may also require conditions of acceptance. If the subcontractor acts as the general subcontractor, SLAC will evaluate whether it has adequate knowledge and experience to supervise lower tier subcontractors.

1 Company Company Name Year Founded

Address Phone

License Classifications (if construction use California License Classification) License #

2 Types of Work / Trades List types of work and/or trades, whether self-performed or managed, to be done at SLAC (qualification will be valid for what is listed). Your firm must be properly licensed in California to perform the proposed work.

Description (if construction list California License Classification and description: eg, B - General Building) Manage? Self-perform?

1 As SLAC is a contractor to the Department of Energy, all outside contractors working at SLAC are considered subcontractors. Consequently, a contractor considered a “general contractor” outside of SLAC is considered a “general subcontractor” at SLAC.

2 Construction work is defined as the combination of erection, installation, assembly, demolition, or fabrication activities involved to create a new facility or to alter, add to, rehabilitate, dismantle, or remove an existing facility. It also includes the alteration and repair (including dredging, excavating, and painting) of buildings, structures, or other real property, as well as any construction, demolition, and excavation activities conducted as part of environmental restoration or remediation efforts.

3 Service work is defined as any work involving maintenance, repair, cleaning, or testing; technical or administrative services; or other tasks that are not construction activities. Service work may be associated with a construction project. High-risk service work is service work that has an above average risk of a serious injury or illness, environmental release, or property damage incident occurring.

https://esh.slac.stanford.edu/general/subcontractor/ https://www-internal.slac.stanford.edu/esh/docreview/reports/revisions.asp?ProductID=456 https://www-group.slac.stanford.edu/esh/eshmanual/references/subcontractorFormSQF.pdf https://www-group.slac.stanford.edu/esh/eshmanual/references/subcontractorProcedNonGreen.pdf https://www.cslb.ca.gov/About_Us/Library/Licensing_Classifications/ https://www.cslb.ca.gov/About_Us/Library/Licensing_Classifications/

SLAC National Accelerator Laboratory Environment, Safety & Health Division Subcontractor Safety | Subcontractor Safety Qualification Form

21 May 2021 SLAC-I-730-0A21J-027-R010 2 of 5

3 Written Health and Safety Manual Prime subcontractors performing construction or high-risk service work must submit a comprehensive written health and safety manual to SLAC for review. (Even if subcontractors wil opt to follow SLAC’s IIPP rather than their own, they must submit these documents as part of the qualification process.) At a minimum the manual must include the following:

California Injury and Illness Prevention Plan (IIPP) (8 CCR 1509 or 8 CCR 3203) required elements

Code of Safe Practices (8 CCR 1509[b]) (if construction work)

Applicable elements for type of work / trade and activity (see below)

Heat Illness Prevention Program (8 CCR 3395) (if working outdoors or in very warm interior environment)

The manual and code of safe practices must include safety policies and/or procedures for each type of work / trade (as indicated on page 1) and activity (below) you propose to perform or manage at SLAC. The policies and/or procedures must meet the requirements of any listed regulation or standard. A prime subcontractor that will supervise the work of one or more sub-tier contractors must have safety/health manual elements for each area of its work and the work of its sub-tier contractors.

Check each applicable activity below that you might perform or manage while working at SLAC.

Hazardous Energy Control (Lockout / Tagout) Concrete Placing and Finishing

Welding, Cutting, or Other Hot Work Demolition

Power Tool Use Housekeeping

Material Handling – Manual Heavy Equipment Use (backhoe, excavator, etc.)

Material Handling – Mechanical (forklifts, gradalls, etc) Working within the Limited Approach Boundary of Exposed Electrical Parts

Hoisting and Rigging Respirator Use

Working from Heights (fall protection, ladder safety) Other:

Scaffold Erection Other:

Use of Scissor and Boom Lifts Other:

Confined Space Entry Other:

These documents are submitted with the subcontractor’s initial SQF; they do not need to be resubmitted with each SQF unless the proposed scope of work changes or the documents on file with SLAC become outdated.

Select one:

Written safety manual attached Version on file with SLAC is current and applicable to proposed work (version date: _______________) https://www.dir.ca.gov/Title8/1509.html https://www.dir.ca.gov/Title8/3203.html https://www.dir.ca.gov/Title8/1509.html https://www.dir.ca.gov/title8/3395.html

Subcontractor Safety | Subcontractor Safety Qualification Form

21 May 2021 SLAC-I-730-0A21J-027-R010 3 of 5

4 Firm Project Experience Please complete this page (or attach) with information about your company’s project experience that is relevant to the type of work listed on page

1. List at least three projects. If bidding as a general subcontractor, firm must have adequate knowledge and experience to supervise lower tier subcontractors. Superintendent / foreman (construction)/ site manager / supervisor (service) refers to the on-site staff person who directly supervised the project’s line workers.

4.1 Project 1

Client or General Contractor Name

Project Name

Project Location Contract Amount

Project Start Date Project End Date

Project Description

Contact Name (Client or GC) Phone E-mail

May we contact concerning your safety / environmental performance? Yes No

Project Manager Superintendent / Foreman / Site Manager / Supervisor

4.2 Project 2

Client or General Contractor Name

Project Name

Project Location Contract Amount

Project Start Date Project End Date

Project Description

Contact Name (Client or GC) Phone E-mail

May we contact concerning your safety / environmental performance? Yes No

Project Manager Superintendent / Foreman / Site Manager / Supervisor

4.3 Project 3

Client or General Contractor Name

Project Name

Project Location Contract Amount

Project Start Date Project End Date

Project Description

Contact Name (Client or GC) Phone E-mail

May we contact concerning your safety / environmental performance? Yes No

Project Manager Superintendent / Foreman / Site Manager / Supervisor

Subcontractor Safety | Subcontractor Safety Qualification Form

21 May 2021 SLAC-I-730-0A21J-027-R010 4 of 5

5 Incident History Submit the following information for review. After February 1, provide data for previous calendar year. Refer to your company’s OSHA Form 300 (Log) and OSHA Form 300A (Summary) for each of the past three years.

NAICS Code: ____ Previous Year 1 20__

Previous Year 2 20__

Previous Year 3 20__

3 Year Total Y1+Y2+Y3

Number of Recordable Cases [Form 300A: Sum of H+I+J]

Number of DART Cases (Days Away, Restricted, or Transferred) [Form 300A: Sum of H+I]

Number of Days Away from Work [Form 300A: K]

Number of Days on Job Restriction or Transfer [Form 300A: L]

Total Hours Worked [Form 300A: right side of page]

Fatalities [Form 300A: G]

OSHA (or State OSHA) Citations

Current Worker’s Compensation Experience Modification Rate (EMR) (or other modifier)

Submit the following supporting documentation:

1. Copies of past three years OSHA Form 300 (Log) and OSHA Form 300A (Summary). Mask names for privacy. Attached

2. Official documentation of current workers’ compensation insurance experience modification rate (letter from insurer or broker on their letterhead or copy of WCIRB printout). Attached

3. Official copy of OSHA (or state OSHA) citation(s) received over past three years. Provide details and circumstances of the violation and describe what corrective actions have been taken. Attached N/A

4. Description of any fatalities including the cause and corrective/preventive actions taken since the incident. Attached N/A

6 Required Supporting Documents Submit the following required documents. This form will not be accepted by SLAC without all of these.

1. Comprehensive company health and safety manual: Attached Version SLAC has on file is still valid

2. Firm project experience: Attached Page on this form completed

3. Copies of past three years’ OSHA Form 300 (Log) and OSHA Form 300A (Summary). Mask names for privacy. Attached

4. Insurer experience modification rate (or other rate modifier) documentation (letter or WCIRB printout) Attached

5. Official record of OSHA citation(s) received and explanation of corrective actions taken: Attached N/A

6. Description of any fatalities including the cause and any corrective/preventive action taken since: Attached N/A https://www.bls.gov/bls/naics.htm

Subcontractor Safety | Subcontractor Safety Qualification Form

21 May 2021 SLAC-I-730-0A21J-027-R010 5 of 5

7 Subcontractor Acknowledgement Firm attests that the information presented here is accurate and truthful. Failure to provide accurate information may result in disqualification. Firm acknowledges that it is responsible for the safety of its workers and its sub-tier workers. Firm represents that all employees and sub-tier subcontractors have, or will have, the required training to perform their contracted work safely, prior to the start of work. (Upon contract award, records of current training must be presented with the site-specific safety plan.)

Sign the page with an official electronic signature or print the document, sign it, and scan as pdf. Do not leave this form in editable pdf format.

Name Date

Signature Phone

Title Cell

Company Name E-mail