SUBCONTRACTOR’S ES&H HISTORY QUESTIONNAIRE

Contract No. / Bechtel (Entity)
Subcontractor / Job No.
1. EMR (US Projects Only)
1A. List your firm’s Interstate Experience Modification Rate (EMR) for the three most recent years and total hours worked.
Year ___ / E.M.R. / Hours Worked
Year ___ / E.M.R. / Hours Worked
Year ___ / E.M.R. / Hours Worked
1B. If the state where the project is located has an EMR rating system, provide the state EMR for the three most recent years and total hours worked.
Year ___ / E.M.R. / Hours Worked
Year ___ / E.M.R. / Hours Worked
Year ___ / E.M.R. / Hours Worked
2.Use your last year’s OSHA No. 300 Log (or equivalent non-U.S. record) to fill in. Please include the OSHA 300 Log with employees’ names omitted
Number of injuries and illnesses:
a. Number of lost workday cases
b. Number of restricted workday cases
c. Number of cases with medical attention only
d. Number of fatalities
3. Check your type of work:
 Non-Residential Building Heavy (Non-highway) Construction Electrical Mechanical
 Other (State Type)
4. Are accident reports (OSHA 300 and OSHA Form 301) and report summaries sent to the following and how often?
No / Yes / Monthly / Quarterly / Annually
Project Supervisor/CSM/FM /  /  /  /  / 
Vice President/Manager of Construction /  /  /  /  / 
Site Director /  /  /  /  / 
President of Firm /  /  /  /  / 
5. Do you hold site safety meetings for field employees both Manual and Non-Manual?
 Yes /  No
How often? /  Weekly /  Biweekly /  Monthly /  Less often, as needed
6. Do you conduct project safety inspections?
 Yes /  No
How often? /  Weekly /  Biweekly /  Monthly /  Less often, as needed
7. How are accident records and accident summaries kept? How often are they reported?
No / Yes / Monthly / Annually
Accidents totaled for the entire company /  /  /  / 
Accidents totaled by project /  /  /  / 
  • Subtotaled by supervisor
/  /  /  / 
  • Subtotaled by foreman
/  /  /  / 
8. How are costs of individual accidents kept? How often are they reported?
No / Yes / Monthly / Annually
Costs totaled for the entire company /  /  /  / 
Costs totaled by project /  /  /  / 
  • Subtotaled by supervisor
/  /  /  / 
  • Subtotaled by foreman
/  /  /  / 
9.List key ES&H personnel planned for this project. List name, expected position and safety performance on last three projects (OSHA Recordable and Lost Workday Case Incident (LWCI) rates). Provide a resume as required by the Data Form titled RESUMES OF KEY PERSONNEL.
NAME / POSITION / PROJECT / RECORDABLE RATE / LWCI


SUBCONTRACTOR’S ES&H HISTORY QUESTIONNAIRE (Cont’d)

Contract No. / Bechtel (Entity)
Subcontractor / Job No.
10. Do you have a written safety program?
 Yes /  No
If yes, submit a copy for evaluation
11. Do you have an orientation program for new hires?
 Yes /  No
If yes, does it include instruction on the following?
No / Yes / No / Yes
a.Head Protection /  /  / j.Fires, barricades, flagging /  / 
b.Eye Protection /  /  / k.First-aid facilities /  / 
c.Hearing Protection /  /  / l.Emergency procedures /  / 
d.Respiratory Protection /  /  / m.Toxic substances /  / 
e.Foot protection /  /  / n.Trenching and excavation /  / 
f.Fall protection /  /  / o.Signs, barricades, flagging /  / 
g.Scaffolding /  /  / p.Electrical safety /  / 
h.Perimeter guarding /  /  / q.Rigging and crane safety /  / 
i.Housekeeping /  /  / r.Road safety (driving) /  / 
Submit a copy for evaluation.
12. Do you have a program for newly hired or promoted foremen?
 Yes /  No
If yes, does it include instruction of the following:
No / Yes / No / Yes
a. Safe work practices /  /  / e. First-aid procedures /  / 
b. Safety Supervision /  /  / f. Accident Investigation /  / 
c. Toolbox meetings /  /  / g. Fire Protection and prevention /  / 
d. Emergency procedures /  /  / h. New worker orientation /  / 
Submit a copy for evaluation.
13. Do you hold employee “toolbox” safety meetings?
 Yes /  No
How often? /  Weekly /  Biweekly /  Monthly /  Less often, as needed
14. Do you have a written Hazard Communication program?
 Yes /  No
If yes, how is it implemented on each project?
15. Do you have/require M.S.D.S. for material/chemicals/equipment than you expect to use/have on this project?
 Yes /  No
If yes, explain field procedure for informing employees about potential hazards:
16. List three (3) client references that could verify the quality and management commitment of your safety program.
1. / Name / Address / Phone
2. / Name / Address / Phone
3. / Name / Address / Phone