/ MATERIALS / MA-MGN-SFM-00-0004
Rev. 3
SUPPLIER QUALIFICATION –
SELF AUDIT QUESTIONNAIRE / 05-Aug-2015
Page 1 of 13
Supplier/Contractor Name:
Supplier/Contractor Address:
Bank Account Details:
General Telephone: / General Fax:
General Email: / Website:

Quality Representative

Name: / Title:
Telephone/Extension: / Email Address:
Products/Services Offered:

Employee Count

Officers / Managers/Supervisors / Engineers / Office Staff / QA/QC Staff / HSE Staff / Total Staff
Pre-Audit Question / Yes / No
1) Are you third party certified (ISO 9000/TS16949/RC14001)?
2) Do you apply statistical process controls?
3) Does the supplier agree to upgrade their system to meet audit requirements?

Name & Title of Company Officer responsible for ensuring the accuracy of this document:

Name: ______Title:______Date:______

Signature:

For Q-Chem Use Only:

Q-Chem

Evaluated by

Printed nameSignature / Date

Q-Chem

Reviewed By

Printed nameSignature / Date

Q-Chem

Materials Manager

Printed nameSignature / Date

SUPPLIER/CONTRACTOR INFORMATION:
SUPPLIER/CONTRACTOR COMPANY NAME:
DIVISION/DISTRICT:
MANAGER:
SAFETY CONTACT: / Phone (……...... ) Fax (…………………..)
TYPE OF WORK PERFORMED:
TRANSPORTATION, MAINTENANCE, CONSTRUCTION, ETC.:
KIND OF OPERATION I.E. OFFSHORE OR ONSHORE:

SECTION-1 INJURY /INCIDENT DATA

EMPLOYEE WORKHOURS
PLEASE SHOW THE AVERAGE NUMBER OF EMPLOYEES AND TOTALWORKHOURS FOR THE LAST FOUR (4) YEARS FOR THE COMPANY /DIVISION /DISTRICT SHOWN ABOVE.
Please provide data for the current year and three previous years. Fill in years. / Current Year / 20__ / 20__ / 20__
NUMBER OF EMPLOYEES
TOTAL WORKHOURS
Occupational Injury/Illness experience
PLEASE PROVIDE SHOW THE OCCUPATIONAL INJURY/ILLNESS EXPERIENCE FOR THE LAST FOUR (4) YEARS FOR THE COMPANY/DIVISION DISTRICT SHOWN ABOVE.
Please provide data for the current year and three previous years. Fill in years. / Current Year / 20__ / 20__ / 20__
NUMBER OF FATALITIES
NUMBER OF LOST WORKDAY CASES
(An injury/illness case where an incident in the work environment causes an individual to be unable to work for one full shift or more beginning on the day following the incident.)
TOTAL NUMBER OF LOST WORKDAYS
(Sum of number of lost days from each lost workday case.)
Please provide data for the current year and three previous years. Fill in years. / Current Year / 20__ / 20__ / 20__
NUMBER OF MEDICAL TREATMENT CASES
(An injury/illness case where an incident in the work environment required or resulted in:
  • Medication or treatment requiring prescription by licensed healthcare professional
  • Loss of consciousness for any length of time
  • Immunization or hypodermic injection other than tetanus immunization
  • Stitches, sutures, or staples for wound closure
  • Rigid means of immobilization such as cervical collar, hard splints, or plaster cast (except when used as a precaution for transporting an accident victim)
  • Fracture or break of any bone or tooth
  • Punctured or ruptured eardrum
  • Hospitalization)

NUMBER OF RESTRICTED WORK CASES
(An injury/illness where an incidentin the work environment (beginning the day after the incident occurs) results in:
  • The contractor employer keeping an employee from performing one or more of the regular duties of the employee’s work;
  • The contractor employer keeping the employee from working a full schedule the employee was originally scheduled to work
  • A licensed healthcare professional recommends the employee not perform one or more of the regular duties of the employee’s work;
  • A licensed healthcare professional recommends the employee not work a full schedule the employee was originally scheduled to work
NOTE: Regular duties are defined as those work activities an individual regularly performs at least once per week.)
TOTAL NUMBER OF RESTRICTED WORKDAYS
(Sum total of number of days in which work was restricted from each restricted workday case.)
NUMBER OF FIRST-AID CASES
(Any injury/illness where an incident in the work environment does not meet the definition of a Restricted Work Case, Medical Treatment Case or Lost Workday Case.)
CONTRACTORS ARE REQUIRED TO SUBMIT A PHOTOCOPY OF THEIR WORKERS COMPENSATION INSURANCE POLICY AND PROPERTY LIABILITY INSURANCE

SECTION 2: AWARENESS OF Q-CHEM HSE PROGRAMS

We have reviewed the contractual exhibit(s) and terms and conditions outlining the contractor company’s responsibility to follow all applicable Q-Chem HSE rules, regulations, procedures, and requirements. / YES  / NO 
We have reviewed the terms and conditions outlining the contractor company’s responsibility to follow all applicable laws, regulations, and codes. / YES  / NO 
We have reviewed the terms and conditions outlining contractor company’s selection and use of sub-contractor companies. / YES  / NO 
NOTE: INCLUDE DATA ON ALL SUB CONTRACTORS TO BE USED ON THE JOB ON SEPARATE, IDENTICAL SHEETS.
CONTRACTOR:
DIV/DIST:
PREPARED BY:
DATE:

SECTION 3: CONTRACTOR HSE PROGRAM

HEALTH, SAFETY & ENVIRONMENTAL MANAGEMENT:
Name of highest ranking HSE professional in the company:
Name: / Title: / Telephone:
Certifications: / Fax:
This person reports to: / Title:
Do you have or provide:
Yes NoFull-time Company HSE Manager / Director? / Yes NoSpecific HSE training program for supervisors?
Yes NoFull-time Client Site HSE Supervisor? / Yes NoCompany-paid HSE training?
HEALTH, SAFETY, & ENVIRONMENTAL PROGRAMS / PROCEDURES:
Yes NoDo you have a written Health, Safety, & Environmental Program?
If yes, does the program address the following key elements:
Yes NoHSE Policy? / Yes NoPeriodic HSE performance audits / reviews that are documented?
Yes NoManagement commitment and expectations for HSE? / Yes NoHSE Incentive Program?
Yes NoHSE accountabilities and responsibilities for managers, supervisors, and employees? / Yes NoHSE hazard recognition and control?
Yes NoRequirements for your employees to follow the HSE rules of the client?
Yes NoRequirements for your employees to advise the client of any unique hazards presented by your work?
Yes NoRequirements for your employees to advise the client of any hazards found by your employees?
Yes NoDo you have personnel trained to perform first aid and CPR?
Do you have written Safe Work Practices and procedures for:
Yes NoEquipment Lockout and Tagout (LOTO)? / Yes NoConfined Space Entry?
Yes NoHeat Stress Prevention? / Yes NoHot Work / Fire Watch?
Yes NoFall Protection? / Yes NoPersonal Protective Equipment?
Yes NoHearing Conservation? / Yes NoLine Breaking / Vessel Opening?
Yes NoRespiratory Protection? / Yes NoHazard Communication?
Yes NoAccident/Incident Reporting? / Yes NoExcavations?
Yes NoHousekeeping? / Yes NoScaffold Building /Scaffold Use?
Yes NoVehicle Safety / Maintenance / Inspection? / Yes NoPortable Electrical/Power Tools?
Yes NoErgonomics? / Yes NoPortable Equipment Grounding Assurance?
Yes NoFlammable / Combustible Liquids? / Yes NoCompressed Gas Cylinders?
Yes NoHazardous Materials Training? / Yes NoPowered Industrial Vehicles (Cranes, Forklifts, manlifts, etc.)?
Yes NoWaste Disposal/Waste Minimization/Spill Prevention? / Yes NoSpecialized Equipment (e.g. hydroblasters, extractors, etc.)?
Health, Safety, and Environmental Communications:
Yes NoDo your Supervisors and Lead Workers speak and comprehend English such that they can understand and perform their assigned tasks safely without an interpreter?
If not, provide a description of your plan to assure that they can safely perform their jobs.
Do you hold client site HSE meetings for:
Yes NoField Supervisors? / Frequency:
Yes NoEmployees? / Frequency:
Yes NoNew Hires/Transfers? / Frequency:
Yes NoSubcontractors? / Frequency:
Yes NoAre the safety, health and environmental meetings documented?
Yes NoDo you conduct client site HSE inspections?
Yes NoDo you conduct Health, Safety, & Environmental program audits?
Yes NoAre audits and corrections of deficiencies documented?
Personal Protective Equipment (PPE):
Yes NoIs applicable PPE provided for employees? / Yes NoDo you have a program to ensure that PPE is inspected and maintained?
Mobile Equipment:
Yes NoDo you have a system for establishing applicable health, safety, and environmental specifications for mobile equipment?
Yes NoDo you conduct inspections on mobile equipment e.g., cranes, forklifts, manlifts) in compliance with regulatory requirements?
Yes NoDo you maintain mobile equipment in compliance with regulatory requirements?
Yes NoDo you maintain the applicable inspection and maintenance certification records for mobile equipment?
Subcontractors:
Yes NoDo you use subcontractors? (If no, skip to next section)
Yes NoDo you use HSE performance criteria in selection of subcontractors?
Yes NoDo you evaluate the ability of subcontractors to comply with applicable safety health and environmental requirements as part of the selection process?
Yes NoDo you require your subcontractors to have a written HSE program?
Do you include your subcontractors in:
Yes NoHSE Orientations?
Yes NoHSE Meetings?
Yes NoHSE Inspections?
Yes NoHSE Audits?
HEALTH, SAFETY, & ENVIRONMENTAL TRAINING
Yes NoDo you have a HSE training program for your employees?
Yes NoDo your employees receive HSE training prior to beginning active work?
Yes NoDo your employees receive refresher HSE training? / Frequency:
Yes NoIs employee HSE training documented?
Yes NoAre all employees trained in the work practices needed to safely perform his job prior to beginning active work?
Yes NoAre all employees trained on the tools and equipment needed to perform his job prior to beginning active work?
INFORMATION SUBMITTAL
PLEASE PROVIDE A COPY OF THE FOLLOWING DOCUMENTS TO ASSIST US IN OUR OVERALL EVALUATION.
INSURANCE CERTIFICATE(S) / YES  / NO 
HSE POLICY(S) / YES  / NO 
HSE/SAFETY MANUAL / YES  / NO 
ORGANIZATION CHART/EXPERIENCE OF HSE STAFF / YES  / NO 
HSE ORIENTATION/TRAINING PROGRAM OUTLINE / YES  / NO 
HSE INSPECTION/AUDIT PROGRAM FORM / CHECKLIST(S) / YES  / NO 
INCIDENT REPORTING PROCEDURE / FORMS / YES  / NO 
HSE PROCEDURE/PROGRAM AS INDICATED BELOW: / YES  / NO 
  • Hazardous Energy Control / Lockout and Tagout (LOTO)
/ YES  / NO 
  • Confined Space Entry
/ YES  / NO 
  • Fall Protection/Working at Heights
/ YES  / NO 
  • Personal Protective Equipment (PPE)
/ YES  / NO 
  • Portable Electric/Power Equipment
/ YES  / NO 
  • Vehicle Safety
/ YES  / NO 
  • Heat Stress Prevention
/ YES  / NO 
List of major equipment (e.g., cranes, generators, industrial trucks, power supplies, etc) your company will be using for work at this facility. / YES  / NO 

SECTION 4: REGULATORY COMPLIANCE AND ENVIRONMENTAL/PROPERTY/DAMAGE INCIDENT EXPERIENCE

PLEASE SHOW THE INDUSTRIAL ENVIRONMENTAL AND PROPERTY/DAMAGE EXPERIENCE FOR THE LAST FOUR (4) YEARS FOR THE COMPANY /DIVISION /DISTRICT SHOWN ABOVE.
Please provide data for the current year and three previous years. Fill in years. / Current Year / 20__ / 20__ / 20__
NUMBER OF REPORTED PERMIT EXCEEDANCES (AIR/WATER).
NUMBER OF NOTICES OF VIOLATION
AMOUNT OF FINES/PENALTIES PAID
NUMBER OF FIRES /EXPLOSIONS (>US$25,000).
NUMBER OF PROPERTY DAMAGE INCIDENTS (>US$25,000).
NUMBER OF TOTAL OF INCIDENTS/NEAR MISSES
NUMBER OF CRISIS/EMERGENCY/PREPAREDNESS EXERCISES
NOTE: INCLUDE DATA ON ALL SUB CONTRACTORS TO BE USED ON THE JOB ON SEPARATE, IDENTICAL SHEETS.
CONTRACTOR:
DIV/DIST:
PREPARED BY:
DATE:

SECTION 5: QUALITY SYSTEM

Questions

/ Answers
To what standard is your Quality System certified, (ie. QS, TS or audit schedule to achieve TS certification)? Attach copy of relevant certificate(s)
Do you have in-house machine and product design capabilities?
Do you have an in-house machine shop?
Do you have in-house facilities management?
Do you have a safety program?

Questions

/ Answers
Do you have in-house testing or do you utilize an outside lab? Are these resources accredited?
Do you maintain lot control for inventory from raw materials through to finished goods?
How long do you retain quality records? Can the records be transmitted electronically?
Do you utilize end of line lot control? If yes, are those lot numbers printed on the finished product boxes/packs?
How are process efficiencies tracked and monitored? How are they communicated to management?
How do you utilize Statistical Process Control?
How are your production and design specifications controlled?
What is your typical employee turnover broken down by salary and hourly?
How are your employees trained and monitored?
What is your employee to supervisor ratio?
How often do your employees receive a documented performance review?
How do you manage first in first out inventory control for raw materials and finished goods?
Are you prepared to immediately notify us of non-conforming product and recall / replace said product should the need arise?
Are you current regarding Substances of Concern regulations?

SECTION 5: QA/QC

Item

/ Manufacturing Process / Aspect / YES / NO / N/A
Do you maintain a documented quality manual describing your Quality System?
Describe:
Are controls exercised over the approval and revision of internal documents, (e.g. procedures, forms, drawings, specifications), external documents? (e.g. flow-down of customer requirements, customer drawings, industry standards)?
Describe:
Are controls exercised over the filing, maintenance, and disposal of hard-copy records?
Describe:
Is regular backup, restore verification, anti-virus, and other relevant maintenance of your computers/servers/networks conducted?
Describe:
Does a quality policy exist, which is articulated by senior management?
Describe:
Is the quality policy communicated and understood within the organization?
Explain:
Does the quality policy emphasize customer focus, attainment of objectives, and continual improvement?
Explain:
Is the quality policy reviewed periodically for appropriateness and continuing suitability?
Explain:
Is planning conducted to achieve the objectives articulated by the quality policy?
Describe:
Is planning conducted in conjunction with Quality System development and revision, to ensure the achievement of objectives articulated by the quality policy?
Explain:
Are responsibilities, authorities, qualifications and skills, and organizational relationships defined? (e.g. job specs, org chart)
Explain:
Are quality and other operational performance measurements communicated to management and staff?
How, when:

Item

/ Manufacturing Process / Aspect / YES / NO / N/A
Are regular management review meetings conducted; which cover (e.g.) quality and other operational performance issues, customer feedback, audit results, setting of goals and objectives, and assignment of resources to achieve goals and objectives?
Describe:
Is employee competence regularly evaluated?
How:
Is training provided as required to ensure continuing employee competence?
Describe:
Is quality awareness training conducted?
Explain:
Is company infrastructure regularly evaluated and maintained? (e.g. plant, equipment, workspace, support services)
Describe:
Is company work environment regularly evaluated and maintained? (e.g. light, heat, noise, cleanliness, morale)
Describe:
Is planning conducted prior to product realization? (e.g. quality plans defining quality requirements, processes, documentation, inspections/tests, records)
Describe:
Are customer requirements reviewed and determined prior to submission of a quotation or acceptance of an order?
Explain:
Are customer communication interfaces and methods defined? (e.g. inquiries, orders/amendments, feedback/complaints, contact names)
Are project management plans implemented for R D/design efforts? (e.g. schedule, budget, tasks, responsibilities, deliverables)
How:
Are project management plans controlled and revised in accordance with project evolution?
Explain:

Item

/ Manufacturing Process / Aspect / YES / NO / N/A
Are design inputs defined and controlled? (e.g. customer or marketing requirements, functional specifications)
Describe:
Are design outputs defined and controlled? (e.g. fabrication drawings, BOMs, specifications, test reports)
Describe:
Are design outputs verified for accuracy and adequacy prior to approval and release? (e.g. procurability, manufacturability, tolerances/acceptance criteria, safety/operational considerations)
How:
Are design reviews conducted at appropriate stages to verify evolving design outputs and to resolve identified design problems?
Explain:
Do design reviews include all appropriate process stakeholders?
Describe:
Do purchase orders to suppliers clearly specify all relevant product and/or service requirements?
Are prospective suppliers audited or otherwise evaluated prior to product and/or service procurement?
How, what frequency, to what standard:
Is the quality and delivery performance of existing suppliers regularly evaluated?
How, what frequency, to what standard:
Are purchased products verified prior to use? (e.g. Receiving inspection, certificates of compliance, etc.)
How:
Are relevant product requirements/information available to production, service and QA/QC staff? (e.g. drawings, specifications, acceptance criteria)
Describe:
Are relevant Work Instructions available?
Describe:
Are product, process, and Quality System improvement initiatives undertaken based upon monitoring, measurement, and analysis of data?
If not, how:

Item

/ Manufacturing Process / Aspect / YES / NO / N/A
Are customer satisfaction, product/service conformity, process measurement, supplier, and trend data analyzed and used as a basis for continual improvement?
If not, how:
Is customer satisfaction regularly monitored and measured?
How:
Is internal quality auditing conducted to ensure ongoing compliance and effectiveness of the Quality System?
Are audits planned and scheduled at defined intervals?
Describe:
Does audit planning take process/area importance and previous audit results into account?
Does internal quality auditing cover the entire Quality System scope?
Are auditors trained and independent of the areas they are auditing?
Are audit results, action s taken, and verification of actions taken presented to senior management?
How:
Are critical processes monitored and measured to ensure the achievement of planned results?
Is effective corrective action taken when planned results are not achieved?
Are nonconforming products or services controlled to prevent their unintended delivery or use?
Are authorities for the disposition of nonconforming products defined?
Is customer approval obtained for use concession of nonconforming products or services?
How:

Item

/ Manufacturing Process / Aspect / YES / NO / N/A
Is a review conducted and appropriate action taken when nonconforming products are detected after their delivery or use? (e.g. product containment, customer advisory, product recall)
How:
Are corrective actions initiated to eliminate the causes of product or process nonconformities?
Does the corrective action process entail problem investigation, analysis, and identification of root cause?
Is corrective action effectiveness verified to ensure that problem recurrence has been eliminated?
Are preventive actions initiated to preclude product or process nonconformities?
Does the preventive action process entail problem investigation, analysis, and identification of cause?
Is preventive action effectiveness verified to ensure that problem occurrence has been prevented?
Are nonconforming products or services that undergo rework subjected to re-verification prior to delivery?
MA-MGN-SFM-00-0004 / Page 1 of 13