"Subcontractor Health and Safety Prequalification Form - Pars Environmental"

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Subcontractor Health and Safety Prequalification Form
General Information
Company Name:
Phone:
Fax:
Street Address
Mailing Address
Health and Safety Management
Highest ranking health/safety professional in company:
Name:
Title:
Phone:
FAX:
Email:
Certifications/Qualifications (CSP, CIH, etc):
Do you have or provide:
Fulltime Health/Safety Director (yes or no)?
Fulltime Health/Safety Supervisor (yes or no)?
Fulltime Job Health/Safety Coordinator (yes or no)?
Health/Safety Incentive Program (yes or no)?
Company paid Health/Safety Training (yes or no)?
Health and Safety Programs and Procedures
Do you have a written health and safety program (yes or no)?
Do you have a written program that address the following key elements:
Management commitment and expectations (yes or no)?
Employee participation (yes or no)?
Accountability and responsibility for managers, supervisors, and employees (yes or no)?
Resources for meeting safety and health requirements (yes or no)?
Periodic health and safety performance appraisals for all employees (yes or no)?
Hazard recognition and control (yes or no)?
Do you have a written program that satisfies your responsibility under the law for:
Ensuring your employees follow the safety rules of the facility/project location (yes or no)?
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Subcontractor Health and Safety Prequalification Form
General Information
Company Name:
Phone:
Fax:
Street Address
Mailing Address
Health and Safety Management
Highest ranking health/safety professional in company:
Name:
Title:
Phone:
FAX:
Email:
Certifications/Qualifications (CSP, CIH, etc):
Do you have or provide:
Fulltime Health/Safety Director (yes or no)?
Fulltime Health/Safety Supervisor (yes or no)?
Fulltime Job Health/Safety Coordinator (yes or no)?
Health/Safety Incentive Program (yes or no)?
Company paid Health/Safety Training (yes or no)?
Health and Safety Programs and Procedures
Do you have a written health and safety program (yes or no)?
Do you have a written program that address the following key elements:
Management commitment and expectations (yes or no)?
Employee participation (yes or no)?
Accountability and responsibility for managers, supervisors, and employees (yes or no)?
Resources for meeting safety and health requirements (yes or no)?
Periodic health and safety performance appraisals for all employees (yes or no)?
Hazard recognition and control (yes or no)?
Do you have a written program that satisfies your responsibility under the law for:
Ensuring your employees follow the safety rules of the facility/project location (yes or no)?
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Subcontractor Health and Safety Prequalification Form
Advising clients of unique work hazards, and/or any found by your employees (yes or no)?
Do you have a written program that includes work practices and procedures such as:
Equipment Lockout and Tagout (yes or no)?
Confined Space Entry (yes, no, or NA)?
Injury and Illness Reporting and Recording (yes or no)?
Fall Protection (yes, no, or NA)?
Personal Protective Equipment (yes or no)?
Portable Power Tools (yes or no)?
Electrical Safety (yes or no)?
Vehicle Safety (yes, no, or NA)?
Compressed Gas Cylinders (yes, no, or NA)?
Electrical Assured Grounding or Full Use of GFCI (yes, no, or NA)?
Powered Industrial Vehicles – cranes, Forklifts, JLGs, etc (yes, no, or NA)?
Housekeeping (yes or no)?
Accident/Incident Reporting (yes or no)?
Unsafe Condition Reporting (yes or no)?
Emergency Preparedness, including an evacuation plan (yes or no)?
Waste Disposal (yes or no)?
Back Injury Prevention (yes or no)?
Do you have a written program for each of the following:
Hearing Conservation (yes, no, or NA)?
Respiratory Protection (yes, no, or NA)?
If you have respiratory protection program, have employees been:
Trained (yes or no)?
Fit Tested (yes or no)?
Medically Approved (yes or no)?
Hazard Communication (yes or no)?
Have employees received documented training for all of your written programs (yes or no)?
Do you have an employee substance abuse program (yes or no)?
If you have a substance abuse program, does it include the following:
Pre-placement Testing (yes or no)?
Random Testing (yes or no)?
Testing for Cause (yes or no)?
DOT Compliant Testing (yes or no)?
Do you conduct medical examinations for:
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Subcontractor Health and Safety Prequalification Form
Pre-placement (yes or no)?
Hearing Function – Audiograms (yes, no, or NA)?
Respiratory – Pulmonary Function (yes, no, or NA)?
List types and describe frequency of all medical examinations:
Do you have personnel trained to perform first aid and CPR (yes or no)?
Describe how you will provide first aid and other medical services to your employees:
Do you provide first aid kits (yes or no)?
Do you hold site health and safety meetings for:
Field Supervisors (yes or no)?
Employees (yes or no)?
New Hires (yes or no)?
Subcontractors (yes or no)?
Are safety and health meetings documented (yes or no)?
Is applicable/required PPE provided to your employees (yes or no)?
Do you have a program to assure PPE is inspected and maintained (yes or no)?
Do you have a corrective process for addressing individual safety deficiencies (yes or no)?
Do you have programs and process that address equipment and material issues including:
Specifications for acquisition of material/equipment (yes or no)?
Inspections of equipment to assure regulatory compliance (yes or no)?
Routine maintenance to assure safe and compliant equipment (yes or no)?
Maintenance of equipment inspection/maintenance/certification records (yes or no)?
Do you use subcontractors (yes or no)
If you answer yes, answer each of the following questions:
Do you use health and safety performance criteria in selecting subcontractors (yes or no)?
Do you evaluate subcontractor health and safety compliance capability during selection (yes or no)?
Do your subcontractors have a written health and safety program (yes or no)?
Do you include your subcontractors in your:
Health and Safety Health Orientation (yes or no)?
Health and Safety Meetings (yes or no)?
Equipment Inspections (yes or no)?
Safety Audits (yes or no)?
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Subcontractor Health and Safety Prequalification Form
How often do you conduct health and safety inspections:
How often do you conduct safety and health program audits:
Are corrections of deficiencies from inspections and audits documented (yes or no)?
Health and Safety Training
Do you have a Health and Safety Orientation Program for new hires (yes or no)?
If Health Orientation Programs are given, describe the programs including their length:
Does your health and safety training provide instruction on the following:
New Worker Orientation (yes or no)?
Safe Work Practices (yes or no)?
Safety Supervision (yes or no)?
Toolbox Meetings (yes or no)?
Emergency Procedures (yes or no)?
First Aid Procedures (yes or no)?
Incident Investigation (yes or no)?
Fire Protection and Prevention (yes or no)?
Safety Intervention (yes or no)?
Hazard Communication (yes or no)?
Are written exams given (yes or no)?
If answer is no, describe how you verify compliance:
Have employees been trained in appropriate job skills (yes or no)?
Do you have a process to access the skills of your workers to assure qualification (yes or no)?
Explain how you assure your workers are qualified to perform their work:
Are employee job skills certified if required by regulations/consensus standards (yes or no)?
Do you know the regulatory health & safety training required for your employees (yes or no)?
Are employees trained in safe work practices for their job (yes or no)?
Is each employee instructed in the following:
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Subcontractor Health and Safety Prequalification Form
Known potential of fire related to their job (yes or no)?
Known potential of explosion related to their job (yes, no, or NA)?
Known potential of toxic release related to their job (yes, no, or NA)?
Investigation and Analysis
Are all incidents investigated to determine their cause (yes or no)?
Are corrective actions or preventive measures taken following any incident (yes or no)?
Do you provide Incident Investigation training within your company (yes or no)?
If yes, who receives this training?
Do you develop statistical summaries that measure your safety performance (yes or no)?
Do you complete and maintain an OSHA 300 Log:
Do you complete and maintain an OSHA 301 or equivalent form for all injuries (yes or no)?
Do you complete and maintain an OSHA 300A Form:
Job Analysis and Observation
Are critical jobs identified and analyzed (yes or no)?
Describe how jobs are identified and analyzed for safety and health hazards:
Are procedures for critical jobs written/reviewed with employee before each job (yes or no)?
Are job observations, such as job safety analysis (JSAs) conducted (yes or no)?
Workers Compensation
List your Interstate Experience Modification Rate for the three most recent years, as evidenced in Workers’
Compensation Insurance premiums:
EMR:
Year:
EMR:
Year:
EMR
Year:
Workers’ Compensation Policy anniversary date:
List states covered by the EMR you are submitting:
Is the EMR for the entire company (yes or no)?
If not for the entire company, describe the department, division, or section:
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