EHS STD 33.055.1 - CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES ANNUAL PREQUALIFICATION FORM – SAFETY
LAST UPDATED: 2017
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This is an Environment, Health, and Safety Mandated Standard/Procedure
All questions must be answered.
Any questions not answered will count negatively against your overall evaluation.
1. Enter date in yyyy-mm-dd format:
2. Legal Name of Company:
3. Operating Name of Company:
4. Government ID Number:
5. Address:
Street:
City:
State/Province: Postal Code: Country:
6. Contact Name:
7. Contact Title:
8. Contact E-mail Address:
9. Contact Phone Number:
10. Contact Fax Number:
11. Select the one category that best describes services offered by your company.
Contractor or Subcontractor Contracted Services
1 Concrete/Masonry Contractor 15 Administrative and Employment Support Services
2 Drilling/Excavation/Trenching 16 Equipment Repair and Maintenance Services
3 Electrical Contractor 17 Food Preparation/Distribution Services
4 General/Building Contractor 18 Furnace/Oven Services
5 Glass Installation/Maintenance 19 Janitorial/Cleaning Services
6 Mining/Exploration Contractor 20 Landscaping or Pest Control Services
7 Painting/Wall Covering Contractor 21 Machine Shop Services
8 Plumbing/Heating/Air Conditioning 22 Material Handling Equipment Services
9 Public Utilities Contractor 23 Professional/Scientific/Tech/Environmental Services
10 Roadway/Highway Contractor 24 Suppliers of Machinery/Equipment/Goods Services
11 Roofing/Siding/Sheet Metal 25 Telecommunication Services
12 Site Preparation/Demolition Contractor 26 Transportation/Trucking/Hauling Services
13 Other Specialty Site Contractor 27 Uniform Cleaning and Laundry Services
14 Structural Steel Erection 28 Waste Collection, Treatment and Disposal Services
30 Other/General Contractor 29 Waste Remediation Services
30 Other/General Services
Enter the one category number from the list above:
If you selected category “30”, describe your services:
12. As part of your company’s safety process, are safety hazard assessments conducted and written job specific safety plans prepared to eliminate safety hazards?
If “Yes”, please attach examples.
Explain your company’s usual process to eliminate safety hazards
13. Please select the box that best describes your organization’s safety committee:
A. Standing safety committee focuses on solving specific problems identified by workers.
B. Management realizes the importance of involving employees in solving safety problems and reducing hazards, but there is no management-labor safety committee.
C. There is no safety committee.
14. Do the following participate in the investigation of all significant incidents or accidents?
A. Owner or Senior Management.
B. Middle Management.
C. Lead Person.
D. Other.
If “Other” is “Yes”, please specify:
15. Have the following changed for your company in the last 3 years?
A. Ownership.
If “Yes”, please provide details.
B. Insurance Carrier.
If “Yes”, please provide details.
C. Other significant changes which may favorably affect safety.
If “Yes”, please provide details.
16. Check all answers that describe the content of your company’s safety training.
A. Basic safety training complies with all local regulations and consensus standards.
B. Select crafts and trades have completed advanced safety training beyond regulatory
requirements.
If “Yes”, please describe specific safety training.
C. Select crew leaders have completed advanced safety training beyond regulatory requirements.
If “Yes”, please describe specific safety training.
17. Documentation of basic safety training exists in the form of:
A. Internal certifications and records.
B. External licenses and certificates issued by governments, professional organizations, trade associations or other recognized authority.
If “Yes”, please attach an example or certificate issued by a recognized authority.
18. Please select the box that best describes your organization’s project managers:
A. Project managers are required to participate in incident investigations, enforce safety rules and address unacceptable field safety inspections or audits.
B. Project managers routinely meet with craft workers and subcontractors to plan/schedule the work and communicate about the potential hazards. Project managers initiate and participate in field safety inspections or audits at various stages of the project.
C. Project management requires tailgate or toolbox safety meetings daily on every shift and is consistently conducting field safety inspections or audits, analyzing incident trends and implement corrective actions to address potential hazards.
19. Your company has a lead person to crew ratio of:
A. Less than or equal to 1 to 7
B. Between 1 to 8 and 1 to 11
C. Between 1 to 12 and 1 to 25
D. Greater than 1 to 25
Comments:
20. The criteria used to qualify safety trainers is established by:
A. Internal training and certifications.
If “Yes”, please describe:
B. External training and certifications from governments, professional organizations, trade associations or other recognized authority.
If “Yes”, please describe:
21. Safety and scheduling coordination meetings with subcontractors are held:
A. Daily
B. Weekly when work is for longer than 1 week.
C. As needed.
D. No Subcontractors are used.
Comments:
22. Indicate all that apply to your company’s substance abuse program.
A. Substance abuse is monitored using random substance tests.
B. Substance abuse is monitored using substance tests for cause or post incident.
C. Substance abuse is monitored by crew leaders trained in substance abuse recognition.
Comments:
23. Your company audits and documents safety meetings, job safety conditions or job safety performance at the rate of:
A. Daily
B. Weekly
C. Monthly
D. Does not audit these.
If audits are performed, please attach the written results from a safety audit.
Comments:
24. Please select the box that best describes your organization’s safety focus:
A. Focus is on productivity and meeting basic OSHA requirements. Construction is inherently dangerous and there is a limit as to what can be done to change it. Generally uses a “lump sum” low bidder as their criteria for subcontractor selection.
B. Safety and health considerations are called out and included in bids.
C. A detailed pre-job risk assessment and safety plan is included in bids. There is evidence of documented project H&S procedures integrated into operational control. Measures and uses both leading and lagging indicators to monitor project safety.
25. Indicate all of the following that have occurred within the last 5 years to any personnel employed or contracted by your company while working.
A. A serious or disabling injury occurred due to any event. Examples of events which could cause a serious or disabling injury include excavation or trench collapse, scaffold failure, confined space entry incident, mobile equipment rollover or contact with electricity.
If “Yes”, please attach details of the injury, the cause and the implemented corrective actions.
B. A serious or disabling injury occurred due to ergonomic factors. Examples of activities would include lifting, pulling, bending, reaching, and vibration resulting in strains or sprains.
If “Yes”, please attach details of the injury, the cause and the implemented corrective actions.
C. A fatality occurred to anyone, including any personnel, visitor, member of the public or any other person due to any circumstances controlled by your company.
If “Yes”, please attach details of the fatality, the cause and the implemented corrective actions.
26. Does a government agency or any other group, such as an insurance carrier, require a log, record or similar document of reportable work related injuries or illnesses? Examples are OSHA Logs, workers compensation claims reports, insurance register of accidents, HSA report, RIDDOR, and etc.
If “Yes”, please attach copies for the last 3 years.
Comments:
27. Enter the following information for the last three years for the total company:
2014 2015 2016
A. Total number of lost/restricted workday
cases (not number of days lost/restricted)
B. Total number of medical treatment cases
C. Total number of first aid cases
D. Total number of injury free events reported
E. Total hours worked, hourly and salaried
F. Accident insurance premium multiplier
28. If you do not have an accident insurance premium multiplier, please explain. Examples of an accident insurance multiplier are: Experience Modification Rate, EMR, Performance Index, Insurers Risk Rating, and etc.:
29. Did your company receive any serious, repeat or criminal citations for health or safety in the last 3 years that involved:
A. Work at a customer’s site, but no injuries or fatalities occurred?
If “Yes”, please describe.
B. Work at a customer’s site where injuries or fatalities occurred?
If “Yes”, please describe.
C. Any work other than at a customer’s site, but no injuries or fatalities occurred?
If “Yes”, please describe.
D. Any work other than at a customer’s site, where injuries or fatalities occurred?
If “Yes”, please describe.
30. At what frequency does your company conduct and document safety activities, such as safety orientations, or safety meetings, or safety inspections?
A. Daily
B. Weekly
C. Monthly
D. Conducts a safety orientation only.
E. None of the above.
Comments:
31. What percent of the work force has been working in the industry for 1 year or more?
A. 0% - 25%
B. 26% - 50%
C. 51% - 75%
D. 76% - 100%
Comments:
32. How often does the owner or the senior management of your company review the safety performance of work crews?
A. Weekly
B. Monthly
C. Quarterly
D. Other
If “Other”, please explain:
33. Please select the box that best describes how your organization selects subcontractors:
A. There is a Contractor’s Responsible Person onsite to monitor and assist with safety program implementation and participate in daily planning meetings. Prequalifying subcontractors on safety replaces low bid. There is a mechanism for submitting safety suggestions or concerns. Workers are not afraid to report incidents or hazards and these will be responded to in a timely manner. Workers have the right to stop work if they feel it is unsafe.
B. Owner safety expectations communicated to contractor’s subcontractors and enforced on site through contractor-subcontractor oversight. Contractor works with each of their subcontractors to ensure there is a site specific safety plan for each job or activity.
C. Prequalification using ‘par’ or industry average lagging indicators only. Subcontractors are told they must comply with in country safety regulations.
34. For how many years have you completed the 33.055.0?
A. Routinely, more than 3 years.
B. Periodically, or at least twice.
C. Once or never before.
Completed By:
Company Name:
Name:
Title:
E-mail address:
Phone number:
Fax number:
Website:
By signing below, I certify that all statements provided herein are true and correct.
Signature: ______
This document is the property of Purchasing Services Co. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used by any other Third Party without express written permission from Purchasing Services Co. It is provided solely for the purpose of gathering information and is not intended for any other purpose. No warranties, guarantees or representations, express or implied, are made as to the utility or effectiveness of the testing methods, processes, products, or procedures described or recommended herein.