DRAFT_B2_08.2_Injury_Illness_Prevention_Plan_Acknowledgement_Form_IIPP.pdf
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- Solicitation number
- SLAC_RFP_368509
- Issued by
-
Department of Energy Office of Science
About this file
This is an Injury and Illness Prevention Plan (IIPP) Acknowledgement Form required by SLAC National Accelerator Laboratory for subcontractors performing work at the facility.
The form documents subcontractor acknowledgement of safety and health program requirements and captures occupational medicine information. Completion is mandatory for both green and non-green work, and submission with the proposal is a prerequisite for issuance of the notice to proceed. The form must be completed by an authorized representative of the subcontractor, preferably the supervisor or foreman, and prime subcontractors are required to flow these requirements down to sub-tier subcontractors. All subcontractors, including sub-tier entities, must complete separate forms. Section 1 requires subcontractors to comply with Department of Energy (DOE) Worker Safety and Health Program requirements (10 CFR 851), which are more stringent than California OSHA IIPP requirements. Subcontractors may either adopt SLAC's 851-compliant IIPP or submit their own 851-compliant IIPP for SLAC review and approval. Section 2 addresses occupational medicine requirements, requiring subcontractors to identify whether they will have employees working on-site for 30 eight-hour days within a 12-month period or enrolled in federally or state-mandated medical or exposure monitoring programs (such as hearing conservation, respiratory protection, lead exposure, or beryllium exposure). If yes, subcontractors must provide comprehensive occupational medicine services and submit their occupational medicine provider contact information. The form also requires dissemination of information regarding the Energy Employees' Occupational Illness Compensation Program Act (EEOICPA) and Former Worker Medical Screening Program (FWP).
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Text version
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.
DRAFT
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