Subcontractor Health And Safety Prequalification Form (Page 2 of 6) in pdf

Subcontractor Health And Safety Prequalification Form Page 2

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:

Page 2 of 6

Subcontractor Health And Safety Prequalification Form Page 2