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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.
| Address of Subcontractor: |
| North American Industry Classification System (NAICS) Code: |
1. Use your OSHA 300 logs to record the number of injuries and illnesses for the last seven years.
| b. | Days Away (DA) Incident Rate2 |
| c. | OSHA Recordable Incident Rate3 |
| 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 |
| 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. | |
3. Do you prequalify lower-tier subcontractors? Yes |_| No |_| 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?
6. Does your company conduct field safety inspections to determine compliance with applicable regulations and procedures?
| 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?
9. Has your company implemented any of the following training programs?
If “Yes” to any, please provide the last date this training was provided.
| |_| |
| |_| |
| 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? |
11. Does your company have written accident investigation procedures?
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:
Include Attachments with Completed Form:
OSHA Form 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 OSHA Citation, if any image1.wmf