Subcontractor Health And Safety Prequalification Form (Page 5 of 6) in pdf

Subcontractor Health And Safety Prequalification Form Page 5

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:

Page 5 of 6

Subcontractor Health And Safety Prequalification Form Page 5