Subcontractor Prequalification Safety Questionnaire.pdf

Subcontractor Safety Prequalification Questionnaire - 1 -

SUBCONTRACTOR SAFETY PREQUALIFICATION QUESTIONNAIRE

Subcontractors shall complete this form and submit it to the LLNS Contract Administrator. The information provided will be reviewed as part of the prequalification criteria. Provide the requested information as completely as possible to facilitate our review and evaluation. Should your company be prequalified, submittals of your safety program(s) will be required for review and approval upon award of a subcontract. If you need more space for any answer, please attach a separate page.

Name of Subcontractor:

Address of Subcontractor:

Contact Name:

Phone Number:

FAX Number:

Email Address:

North American Industry Classification System (NAICS) Code:

Date:

1. Use your OSHA 300 logs to record the number of injuries and illnesses for the last seven years.

YEAR

a. Number of Fatalities1

b. Days Away (DA) Incident Rate2

c. OSHA Recordable Incident Rate3

d. Number of Hours Worked

e. Total Number of Employees on Your Payroll

f. Attach a copy of your OSHA Form 300A for the last seven years.

1 If the answer is more than “0”, provide a written explanation of any fatalities and what corrective measures have been put into place to prevent future incidents.

2 The following formula is used for calculating the

Days Away Incident Rate:

= Number of Days Away Cases (H) x 200,000

Number of Hours Worked

3 The following formula is used for calculating the

OSHA Recordable Incident Rate:

= Number of OSHA Recordable Cases (G+H+I+J) x 200,000

Number of Hours Worked

2. List your company’s workers’ compensation (WC) experience modification rate (EMR) for the three most recent years:

Year Interstate Intrastate a.

b.

c.

d. Provide a letter from your WC insurance carrier certifying the above EMRs.

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 methods that are being implemented by your company to reduce this rate.

No3. Do you prequalify lower-tier subcontractors? Yes

If “Yes”, attach method used to qualify lower-tier subcontractors. If

“No”, do you self-perform 100% of your work?

4. Has your company received an OSHA (or state OSHA) citation within the last five years? Yes No

If “Yes”, attach 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?

5. Does your company have a written occupational safety and health program?

Yes No

6. Does your company conduct field safety inspections to determine compliance with applicable regulations and procedures?

a. Yes No

b. Who conducts these inspections? (Please provide position/title)

c. How often are safety inspections conducted?

7. Does your company have the following on your staff or on retainer?

No Yes How Many Staff Retainer Provide certification number(s)

Occupational Physician

Certified Industrial Hygienist

Certified Safety Professional

Certified Health Physicist

8. Does your company have an orientation program for new hires? Yes No

9. Has your company implemented any of the following training programs?

If “Yes” to any, please provide the last date this training was provided.

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

Construction (OSHA Certified 10 Hours) Ladder/Scaffolding

Construction (OSHA Certified 30 Hours) Lead

Cranes Operations Lockout/Tagout

Electrical Safety Personal Protective Equipment

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, title)?

Subcontractor Safety Prequalification Questionnaire - 3 -

10. Does your company have a program in place to discipline workers who perform unsafe work practices? Yes No

11. Does your company have written accident investigation procedures? Yes No

12. Does your company currently maintain a program in compliance with applicable state “Right to Know” laws and the OSHA

Hazard Communication Standard? Yes No

13. Does your company currently maintain an accident prevention program in compliance with applicable state OSHA regulations? (Required for Alaska, California, Minnesota, Nevada and North Carolina) Yes No N/A

14. Does your company implement a medical surveillance program for employees who work on hazardous waste sites or with hazardous chemicals (i.e., lead, asbestos, benzene, arsenic, formaldehyde, etc.)? Yes No N/A

15. Does your company hold “tailgate/toolbox” safety meetings? Yes No

If yes, how often?

16. Does your company have a written alcohol and substance abuse policy statement?

If “Yes”, does it include the following?

a. 10-panel substance testing?

b. Pre-employment/pre-job assignment testing (within 30 days of pre-job assignment)?

c. Post-accident drug and alcohol testing?

d. Random testing (10 percent per month)?

e. Reasonable suspicion drug and alcohol testing?

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

17. Has your company worked at the LLNL facility in Livermore or Site 300 in the past three years?

Yes No

If “Yes”, what was the most recent project completed?

Completion date: LLNS Contract Administrator:

Construction Manager:

COMPLETED BY:

18. Name of Firm:

Printed Name:

Signature:

Title:

Date:

Include Attachments with Completed Form:

OSHA Form 300/300A

Provide a letter from your WC insurance carrier certifying the above EMRs.

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).

If your current EMR is greater than 1.0, provide a written explanation of the safety methods that are being implemented by your company to reduce this rate.

Subcontractor Prequalification Process of lower tier subcontractors OSHA Citation, if any