B2_DRAFT_08.4_Subcontractor_Safety_Qualification_Form.pdf
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- Attached to
- SLAC Job Order Contract
- Solicitation number
- SLAC_RFP_368624
- Issued by
-
Department of Energy Office of Science
About this file
This is a Subcontractor Safety Qualification Form (SQF) issued by SLAC National Accelerator Laboratory's Environment, Safety & Health Division, effective May 21, 2021. The form applies to prime subcontractors performing construction work or high-risk service work at SLAC and serves as a qualification document valid for one year and for the specific types of work listed.
The form requires subcontractors to complete seven sections: (1) Company information including name, address, phone, and California license classifications; (2) Types of work and trades to be performed, whether self-performed or managed, with proper California licensing required; (3) Comprehensive written health and safety manual submission including California Injury and Illness Prevention Plan (IIPP), Code of Safe Practices for construction work, applicable elements for specific work types/trades, and Heat Illness Prevention Program if working outdoors, with documentation of 16 potential hazardous activities (lockout/tagout, welding, power tools, material handling, hoisting, fall protection, scaffolding, scissor/boom lifts, confined space entry, and others); (4) Firm project experience with at least three completed projects including client/GC name, project details, contract amount, dates, description, and contact information for reference verification; (5) Three-year incident history from OSHA Forms 300 and 300A including recordable cases, DART cases, days away from work, job restrictions, total hours worked, fatalities, OSHA citations, and workers' compensation experience modification rates; (6) Required supporting documentation checklist confirming submission of safety manual, project experience, OSHA forms, experience modification rate documentation, OSHA citation records, and fatality descriptions; and (7) Subcontractor acknowledgement requiring authorized signature attesting to accuracy and truthfulness of information, with acknowledgment that the firm is responsible for worker safety and that all employees and sub-tier subcontractors possess required training prior to work commencement. SLAC reserves the right to accept or reject subcontractors based on qualification criteria and may impose conditions of acceptance.
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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.
DRAFT
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: _______________)
Subcontractor Safety | Subcontractor Safety Qualification Form
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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
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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
Subcontractor Safety | Subcontractor Safety Qualification Form
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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
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