Standardized Safety Questionnaire (SSQ) Offshore and Onshore Copyright 2014-PEC Safety 2014 Standardized Safety Questionnaire
STANDARDIZED SAFETY QUESTIONNAIRE The Operator Development Team (ODT) Standardized Safety Questionnaire (SSQ) is part of a safety information management system. The ODT- SSQ will be used by your present and potential Operators or Large Contractors with subcontractors (Large Contractors) to evaluate your company s training and Environmental, Health and Safety (EHS) systems. The information provided in the SSQ may be confirmed through verifications and/or audits by PEC or directly by the Operators or Large Contractors requesting this information. Intentionally submitting incorrect or misleading information may be grounds for removal from the PEC system and the notification of Operators and Large Contractors that have requested this information. Some Operators require monthly statistical updates; our system requires quarterly updates to the General Safety Incident Statistics section and any changes in your safety information located in the questionnaire. Please take the time to make your submission complete and accurate. Should you have any questions, please contact PEC at 1.800.892.8179 or email us at safety@pecsafety.com. 1. Complete the sections below: at a minimum the taxpayer ID, company name, mailing address, physical address, and primary SSQ contact and SSQ admin person fields must be completed. Taxpayer ID # (If not an USA number, Prefix the ID with a # Symbol): Company Name (Full Legal Name): URL (Company Website Ex: www.company.com): Company Name (Short Version-30 Characters of Less): MAILING ADDRESS Address (Include Zip Code and Country if not an USA address): PHYSICAL ADDRESS Address (Include Zip Code and Country If not an USA number): Area Code and Phone Number (Include Extensions): Area Code and Phone Number (Include Extensions): Fax Number with Area Code: Area Code and Phone Number (Alternate #): Emergency Phone Number with Area Code: SSQ ADMIN CONTACT PERSON (Person in Your Company Who is Responsible for Updating and Maintaining SSQ) Full Name: Title: Area Code and Phone Number: Area Code and Mobile Phone Number: Email (Please Print Clearly): Emergency Phone Number with Area Code: CONTACT (Name of Person You Want to Appear on Your SSQ Homepage as Primary Contact for Your Customers) Full Name: Title: Area Code and Phone Number: Area Code and Mobile Phone Number: Email (Please Print Clearly): Copyright 2014-PEC Safety 1 2014 Standardized Safety Questionnaire
OPERATIONS MANAGER SALES MANAGER Full Name: Full Name: Area Code and Phone Number: Area Code and Phone Number: OPERATIONS MANAGER (CONTINUED) Area Code and Mobile Phone Number: SALES MANAGER (CONTINUED) Area Code and Mobile Phone Number: Email (Please Print Clearly): Email (Please Print Clearly): Countries Where This Company Operates and Covered by SSQ (Please List All): In USA, Which States and/or Provinces? In Venezuela, Which States and/or Provinces? In Trinidad, Which States and/or Provinces? In Mexico, Which States and/or Provinces? SERVICES The Services Section is designed to understand what services you or your company provide. NAICS Code: Choose your primary service. Service Region: If you or your company provide services, equipment, etc. onshore and/or offshore, then choose the appropriate region(s). Services: Based on the Service region(s) chosen, you will choose the services performed on selected region(s). The Operators pay close attention to the services chosen. Some questions are attached to service regions and services. 2. Click this > Find NAICS Code < link to choose the best possible match of NAICS code to the services that your company provides. This code should match the NAICS code recorded on your OSHA 300A form. NAICS Code / NAICS Title: 3. Service Regions: (Example Onshore, Offshore) NOTE: FOR CONTRACTORS WHO MAY PROVIDE SERVICES AND/OR EQUIPMENT FOR OFFSHORE OPERATORS: This information is for contractors who are not sure if they fall under Safety and Environmental Management System (SEMS) requirements. The Center for Offshore Safety defines SEMS contractor as the following: The individual, partnership, firm, or corporation retained by the owner to perform work, provide supplies, or provide equipment. This definition from Center for Offshore Safety also includes subcontractors. Using the definition above, please determine the correct service region(s) below based on the service(s) you provide for the Operator(s). Service regions trigger additional sections to appear in your SSQ. Domestic USA Onshore Oil and Gas Check all that apply Domestic USA Offshore Oil and Gas Check all that apply Domestic USA Beverage Industry Short Form Onshore Contractors Domestic USA Oil & Gas Refining, Retail and Transportation Short Form Offshore Contractors Venezuela Oil and Gas Copyright 2014-PEC Safety 2 2014 Standardized Safety Questionnaire
SERVICES (CONTINUED) NOTES: 1. Services selected are services you or your company perform on Operators premises, including subcontractors who have been hired by you or your company. 2. Definition of Employee: Direct hire individual(s) and subcontractors. 3. Definition of Subcontractor: Someone who is used by you but employed directly by another company. Services below are for the Contractors that have chosen Domestic USA Onshore and/or Domestic USA Offshore Oil & Gas 4. Select Only the Service(s) your company provides for Operator(s). ** SEE ATTACHMENT A FOR LIST OF CURRENT SERVICES IN THE SSQ 5. Please list any other services you or your company provides that are not listed above. 6. Please describe the main service you or your company provides (20 words or less). 7. Do you or your company s employees enter onto Operator(s) properties other than office locations? 8a. Are ALL documents pertaining to this questionnaire available for verification / auditing? (Examples: training records for employees, programs, procedures, processes, documents, etc.) See the note below for more information. NOTE: Throughout the SSQ there are several questions that ask if you have documentation to substantiate your answers. The above question pertains to all such questions. Be aware that information you indicate that you have is subject for review. 8b. If No above, meaning documents pertaining to this questionnaire are NOT available for auditing, please explain: INFORMATION RELEASE SECTION 9. Release to Operators **SEE ATTACHMENT B FOR A COMPLETE LIST OF OPERATORS LOCATED IN THE SSQ 10. Release to Large Contractors with Sub-Contractors **SEE ATTACHMENT C FOR A COMPLETE LIST OF LARGE CONTRACTORS WITH SUB-CONTRACTORS LOCATED IN THE SSQ GENERAL SAFETY INCIDENT STATISTICS SECTION 11. Enter the approximate date your company started operations. (Example: DD / MO / YYYY) 12a. Has you or your company, or the owners of your company, operated under a different name in the last three (3) years? 12b. Please list the names and locations of any companies you, your company, or the owners of your company have operated under the last three years. 13a. Are employees from other offices/districts ever utilized? 13b. If an employee from another office/district is injured, at which office/district is their injury recorded? Copyright 2014-PEC Safety 3 2014 Standardized Safety Questionnaire
2012 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Average Number of Employees per Quarter 1 Exposure or Employee Hours 2 Deaths Away From Work Cases On Job Transfer or Restriction Cases Other Recordable Cases (Remained at Work) Number of Total Recordable Cases 3 TRIR Total Recordable Incident Rate 4 On Job Transfer or Restriction Days Away From Work Days Indicent Rate of Days Away from Work Cases 8 Severity Rate 9 LTA/Total Accident Ratio 10 Fatality Ratio 2010 2011 2012 2013 Year Exposure or Employee Hours Deaths Away From Work Cases Transfer or Restriction Other Recordable Cases (Remained at Work) Number of Total Recordable Cases TRIR Total Recordable Incident Rate On Job Transfer or Restriction Days Away From Work Days Indicent Rate of Days Away from Work Cases LTA/Total Accident Ratio Fatality Ratio GENERAL SAFETY INCIDENT STATISTICS SECTION 14a. List Incident Details for each QTR: INSTRUCTIONS: Table below: Provide the current year-to-date and the last 3 full years of incident information for your company, division or subsidiary. Click the EDIT button to edit a row and the SAVE button to save your edits. INCLUDE EVERYONE IN THE COMPANY (FIELD & OFFICE) AND (OWNER/OPERATOR). All editable OSHA columns can be a zero or a positive number. Notes: 1. If your company performs work on an offshore facility/lease site under jurisdiction of the Bureau of Safety and Environmental Enforcement (BSEE), this data must be provided. 2. If EMR and/or OSHA do not apply to your company, you are still required to complete all collumns & rows. 3. If your company is not eligible for an EMR (Experience Modifier Rate) because; Your company is exempt from maintaining worker s compensation insurance Your company is new (less than 3 yrs. in business) Company has merged with another company then your EMR should be entered as a 1.00, NEVER ZERO. Recordable Cases Number of Days Average Number of Employees per Quarter EMR DART Severity Rate Q4 Q3 Q2 Q1 Q4 Q3 Q2 Q1 Q4 Q3 Q2 Q1 Q4 Q3 Q2 Q1 14b. Three Year Summary: This table is a summary of the latest three calendar years. The year shown in the first column is the latest year in which the incident data was complete. The quarter shown in the second column ins themost recent completed quarter. Recordable Cases Number of Days 5 EMR 6 DART 7 Q4 15. OSHA Verification Documents: If required by your Operator, please upload documents for the indicated year. Copyright 2014-PEC Safety 4 2014 Standardized Safety Questionnaire
GENERAL SAFETY INCIDENT STATISTICS SECTION Year OSHA Verification EMR Verification 2012 2011 2010 16. Please enter any comments below on information in the incident tables: This information should include how many employees actually go to Operator(s) premises. 17a. Specify the basis for exposure or employee 17a. Specify the basis for exposure or employee Check Check hours. hours. Not Answered 8 Hour Shifts 10 Hour Shifts 12 Hour Shifts Other 17b. If Other above, please explain the basis for exposure or employee hours. 1A. EMR Statistics EMR STATISTICS SECTION Year Quarter EMR 2014 4 2014 3 2014 2 2014 1 2013 4 2013 3 2013 2 2013 1 2012 4 2012 3 2012 2 2012 1 Copyright 2014-PEC Safety 5 2014 Standardized Safety Questionnaire
EMR STATISTICS SECTION (CONTINUED) Year Quarter EMR 2011 4 2011 3 2011 2 2011 1 2. EMR Verification Document Upload: If required by your Operator, please upload documents for the indicated year. Please Upload the Latest copy of your EMR documents that can be used to verify your EMR reported above. More than one copy may be uploaded in one year. Year OSHA Verification EMR Verification 2014 2013 2012 2011 TRAINING RECEIVED SECTION Offshore Operators asked that the Offshore SEMS section remain isolated. Therefore, some questions are repeated in other sections. You will only have to answer questions once as your answers will populate repeat questions. Training Changes: Understand that some training has been re-named, added or moved to the Best Practices section. Review your training list for accuracy. 18. Regulatory Training Received by Employees (or yourself if you are a sole proprietorship) NOTE: Make sure you have documentation to support all regulatory training programs that you select. **SEE ATTACHMENT D FOR A COMPLETE LIST OF TRAINING LOCATED IN THE SSQ Regulatory Training The training chosen above will populate below. Required to complete the columns below for each regulatory training chosen. Do you provide this training at the time of hire? Yes No What frequency is this training given? Drop Down Menu: Monthly Quarterly Semi-annually Annually Every 2 Years Every 3 Years Every 4 Years (or More) Only At Hire Only Offered Once Please select the method for conducting the training. Drop Down Menu: Instructor Led Computer Based Video On the Job How do you document the Training? Check All that Apply: Passed Written Evaluation Roster (Including Date / Training Name / Trainees / Instructor Name) Certificate of Successful Completion Copyright 2014-PEC Safety 6 2014 Standardized Safety Questionnaire
TRAINING RECEIVED SECTION (CONTINUED) 19. Best Practice Training Received by Employees (or yourself if you are a sole proprietorship) NOTE: Make sure you have documentation to support all best practice training programs that you select. **SEE ATTACHMENT E FOR A COMPLETE LIST OF BEST PRACTICE TRAINING LOCATED IN THE SSQ Best Practices Training The training chosen above will populate below. Required to complete the columns to the right for each best practices training chosen. Do you provide this training at the time of hire? Yes No What frequency is this training given? Drop Down Menu: Monthly Quarterly Semi-annually Annually Every 2 Years Every 3 Years Every 4 Years (or More) Only At Hire Only Offered Once Please select the method for conducting the training. Drop Down Menu: Instructor Led Computer Based Video On the Job How do you document the Training? Check All that Apply: Passed Written Evaluation Roster (Including Date / Training Name / Trainees / Instructor Name) Certificate of Successful Completion 20. If you provide regulatory training to your employees that is not listed above, then ensure you select Regulatory Training Not Listed in the above list. Also please list the name of each training provided along with any other pertinent information about such training. If you selected No Regulatory Training Conducted above, then please list all reasons why your company does not provide the required regulatory training. NOTE: SafeGulf, SafeLand, and other accredited orientation training programs are specifically covered in the next section. Therefore, please DO NOT list them here. TRAINING QUESTIONS SECTION Offshore Operators asked that the Offshore SEMS section remain isolated. Therefore, some questions are repeated in other sections. You will only have to answer questions once as your answers will populate repeat questions. ADDITIONAL TRAINING QUESTIONS 21. Can you or your company provide documentation that all required Regulatory training pertaining to your primary service chosen in the Services Section of this SSQ has been identified and that employees have been trained accordingly? (Examples: Training plan, training matrix, policy and procedures, etc.) 22. Do you or your company ensure that employees receive refresher training as appropriate? 23. Do you or your company provide its employees with an industry accredited Environental, Health and Safety (EHS) orientation? If yes, select the orientation program(s) you provide and list the names of the accredited training providers utilized for each orientation. NOTE: If you use your own in-house instructors to provide training, use the following format in the text boxes (Industry Accredited Training Provider Name) to indicate In-House instructors: IN-HOUSE- FIRST/LAST Name of Instructor Training Course SafeGulf Accredited Orientation SafeLandUSA Accredited Orientation Other Industry/Accredited Orientation Provided Yes No a. b. c. d. e. f. Accredited Training Provider Name Copyright 2014-PEC Safety 7 2014 Standardized Safety Questionnaire
ADDITIONAL TRAINING QUESTIONS (CONTINUED) 23g. In the previous question, if you indicated your company utilizes an Other Industry/Accredited Orientation. Please provide the name of the Other Industry Accredited Orientation program your company utilizes and also provide any other information that will assist in identifying this accredited orientation. 24. Are your employees trained in the new Global Harmonization System (GHS) requirements? NOTE: See below for more information regarding this question. In March, 2012, OSHA issued regulations requiring companies to comply with changes to the Hazard Communication Standard to meet International requirements for the Global Harmonization System of Classification and Labeling of Chemicals (GHS) (29 CFR 1910.1200). In order to meet the new requirement, all employees must be trained to understand the new label elements and safety data sheets format by December 1, 2013 [1910.1200(j)(1)]. Note: If your answer above is Yes, then Global Harmonization should be chosen in the regulatory Training Section. INSTRUCTOR INFORMATION 25a. Do you or your company have information available to verify that the instructors are certified and / or qualified to teach the subject in which they performed training? 25b. If Yes above, where is the instructor certification/ qualification information located? (Examples: Name of online service, office address, etc.) TRAINING PLAN 26a. Do you or your company have a written training plan that includes all employee job classifications and the required training for each job classification? NOTE: Training Plan: Written document that establishes that all personnel are trained to work safely and are aware of environmental considerations offshore and /or onshore, in accordance with their duties and responsibilities (using job classifications). Training should address the operating procedures, safe work practices and emergency response control measures. 26. If Yes above, who is responsible for your company s training records, training plan and / or training matrix? b. Full Name: c. Job Title: 27. If required by your Operator and you have purchased the Document Upload & Adv Training Tracker Bundle or CAP package, please use the following link to upload the most recent copy of your company s Training Plan. Click Here to Upload Your Training Plan NOTE: If you are uncertain whether or not this is required by the PEC Member Operator(s) you work for, please review the Operators notification letter(s) received or contact PEC Customer Support at 866-647-2338. EMPLOYEE BACKGROUND CHECKS 28a. Do you or your company perform background checks on potential employees? 28b. If Yes above, what types of background checks are performed on potential employees? (Check all that apply.) Copyright 2014-PEC Safety 8 2014 Standardized Safety Questionnaire
Motor Vehicle EMPLOYEE BACKGROUND CHECKS Criminal Credit History Education TWIC State / Federal Identification 29. Do you or your company provide a picture I.D. for employees going on operator(s) properties? 30. Do your managers, supervisors, and employees understand that no weapons or contraband of any type are allowed on the worksite and/or Operator(s) premises? EMPLOYEE EVALUATIONS 31a. Do you or your company have a written process to evaluate employees in the work they perform? 31b. If Yes above, does your company s written process to evaluate employees in the work they perform, include training which enables employees to work safely? 31c. If Yes above, does your company s written process to evaluate in the work they perform, include training on environmental considerations? 32. Do you or your company have fitness for work requirements? 33. How can employee training information be reviewed? (i.e. Name of the online training tracker, office address where files are located, etc.) EMPLOYEE SKILLS AND KNOWLEDGE 34a. Do you or your company have a written employee verification of skills and knowledge program that documents, identifies, develops and manages employees skills and knowledge? 34b. If Yes above, how do you verify your employee s skills and knowledge? (Check all that apply.) How do you verify your employee s skills and knowledge? Observe the employee performing activity safely and proficiently Have employees demonstrate skills at worksite Check How do you verify your employee s skills and knowledge? Provide a written knowledge assessment test on activity Peer review Check Have employees demonstrate skills by simulation Evidence compiled by employee Oral Questioning 34c. If Yes above, are your company s written employee verification of skills and knowledge documented and available for review? 35. Do you or your company have written processes and procedures available to employees for the work they perform? 36. For each job classification identified in your company, do you have a written procedure for determining skills and knowledge for each classification? Note: These job classifications can be located in your training matrix, training plan, etc. Copyright 2014-PEC Safety 9 2014 Standardized Safety Questionnaire
ENVIRONMENTAL, HEALTH AND SAFETY MANAGEMENT SECTION 37. Do you or your company have a written Environmental, Health and Safety (EHS) manual? See note below for more information. Note: This manual is called various names within the industry such as: Policies and Procedures Manual, Safety Manual, and any combinations of the words Health, Safety, and Environmental. In this questionnaire, these programs/policies are referred to as Environmental, Health, and Safety (EHS) Manual. 38. If required by your operator and you have purchased the Document Upload & Adv Training Tracker Bundle or CAP packages, please use the following link to upload the most recent copy of your company s EHS Manual (commonly called a Safety Manual). Click Here to view the EHS Manual Note: If you are uncertain whether or not this is required by the PEC Member Operator(s) you work for, please review the Operators notification letter(s) received or contat PEC Customer Support at 866-647-2338. 39. If Yes above (you have a written EHS manual), is your EHS manual endorsed by upper management? 40. If Yes above, enter (below) the name of the person who is responsible for coordinating your EHS program? a. Name: b. Title: 41a. If Yes above, (you have a written EHS Manual) is the person listed above a full-time position to coordinate your company s EHS program? 42a. If Yes above, is the coordinator of your EHS program also responsible for updating your EHS program? 42. If No above, then please list the person responsible for updating the EHS program. b. Name: c. Title: 43. Does your company establish annual goals in any of the following? Safety, Health, Environmental, Spill Response, Waste Management. A. Safety Yes No B. Health C. Environmental Issues D. Spill Response E. Waste Management 44a. Do you or your company allocate time and resources to train all supervisors in environmental and regulatory compliance? 44. If Yes above: who is responsible for training supervisors in environmental and regulatory compliance? b. Name: c. Title: Copyright 2014-PEC Safety 10 2014 Standardized Safety Questionnaire
ENVIRONMENTAL 45a. Do you or your company have a written environmental program? 45b. If Yes above, do you or your company s environmental program include a Waste Management Plan? 46. Do you or your company have a system in place to control hazardous materials that will be brought to, used and removed from the worksite? 47a. Have you or your company been the reason for a spill on Operator(s) property (on land and/or water) within the last three (3) years? 47. If Yes above, what was the total volume reported for the year(s) that a spill occurred on an Operator(s) property? (Enter the Year (YYYY), Total Volume (Include the Units), and specify if Land or Water for each year.) Only list the years/volume/location when a spill occurred. YEAR (YYYY) TOTAL VOLUME (in units) SPECIFY Land / Water b. c. d. e. f. g. h. i. j. HEALTH AND SAFETY SHORT SERVICE EMPLOYEES 48a. Do you or your company have a written Short Service Employee (SSE) policy that identifies new employees or experienced employees new to your company or new in their position? 48b. If Yes above, does your SSE policy include ways to visually identify a SSE? (Examples: green hard hat, stickers, bands, etc.) 48c. If Yes above, does your SSE policy include a mentor being assigned to the SSE? 48d. If Yes above, does your written SSE policy define the roles and responsibilities of the mentor? 49. If Yes above, (written SSE policy) can you or your company show documentation verifying the skills and knowledge of the SSE in their job prior to being removed from SSE status? 50. If Yes above, (a written SSE policy) do you or your company have documented training requirements (job specific) for new employees or experienced employees new to their position? HEALTH AND SAFETY BEHAVIORAL BASED SAFETY (BBS) 51a. Do you or your company have a written behavioral based safety program in place? 51b. If Yes above, do you or your company s BBS program include documented behavioral observations? 51c. If Yes above, do you or your company perform formal documented trend analysis of behavioral observations? 52. Do you or your company have a documented inventory of critical safe behaviors associated with the services performed for Operator(s)? Copyright 2014-PEC Safety 11 2014 Standardized Safety Questionnaire
SUBCONTRACTORS SECTION Definition of Subcontractor: All sources of services and / or human resources used to perform work for your company including other contractors, temporary labor, and leasing agencies. All subcontractors are required by your Operators and / or Large Contractor to be listed below. It is required that you list the subs that work on the properties of the Operators and / or Large Contractor in which you have released your SSQ and ADV Training Tracker. 53. Do you or your company use subcontractors on Operator(s) premises? 54. If Yes above, please list all of your Subcontractors using the text boxes below. Enter each subcontractor s name and their primary service performed for your company. Once you have completed the subcontractor s name and service, click the Add button to record the subcontractor. Repeat this for each of your subcontractors. Only add the subcontractors that perform work for Operators. Subcontractor Services They Provide for Your Company 1. 2. 3. Subcontractor Services They Provide for Your Company 4. 5. 6. 7. 8. 9. 10. If You Have More Subcontractors to List, Click Here 55. If Yes above,(your company uses subcontractors), do you or your company review the Environmental, Health, and Safety (EHS) systems of subcontractors and ensure they meet or exceed Operator(s) requirements? 56a. If Yes above, (your company reviews the EHS systems of subcontractors and ensures they meet or exceed operator requirements) have you or your company documented the verification of the subcontractor s EHS systems? 56b. If Yes above, what is your process for documenting the verification of subcontractors? Please explain below: Copyright 2014-PEC Safety 12 2014 Standardized Safety Questionnaire
SUBCONTRACTORS SECTION (CONTINUED) 57. If Yes above (your company uses subcontractors), are your subcontractors exposure hours reflected in your company s exposure hours reported in the General Safety Incident Statistics section of this questionnaire? NOTE: These records should be kept by the employer / firm responsible for the day-to-day direction of the employees activities. 58. If Yes above (your company uses subcontractors), do you include subcontractors in Environmental, Health & Safety (EHS) orientations? 59. If Yes above (your company uses subcontractors), do you include subcontractors in EHS training programs? 60. If Yes above (your company uses subcontractors), do you include subcontractors in EHS worksite inspections? 61. If Yes above, do you or your company conduct post-job safety performance evaluations or reviews of your subcontractors? 62. If Yes above (your company uses subcontractors), do you or your company use a temporary labor/leasing agency? SAFETY MEETINGS JOB SAFETY ANALYSIS MECHANICAL INTEGRITY SAFETY MEETINGS 63a. Do you or your company have scheduled, documented employee safety meetings? 63b. If Yes above, do you or your company include environmental topics in conjunction with safety meetings? 63c. If Yes above (your company does have scheduled documented safety meetings), how often do the scheduled documented safety meetings occur? (check just one) Daily Weekly Monthly Quarterly Semi- annually Annually As Needed Other 63. If Yes above, who in your company conducts the scheduled documented employee safety meetings? d. Name: e. Title: 64. Do you or your company hold and document on-site/pre-tour, etc. safety meetings and / or attend Operator sponsored onsite safety meetings? 65. Do you or your company have a safety committee? JOB SAFETY ANALYSIS (JSA) 66a. Do you or your company perform and document Job Safety Analysis (JSA)? See the note below for more inoformation. Note: Job Safety Analysis (JSA) may also be called Job Hazard Analysis (JHA), Job Risk Analysis (JRA), etc. In this questionnaire, this document will be referred to as Job Safety Analysis (JSA). JSAs are a written form between Operator and Contractor that provides information regarding the said job. It includes but is not limited to: a visit to the job site, identifying work control and EHS issues, procedural steps, roles & responsibilities of those involved, pre-job planning (systematic process for determining methods for completing tasks safely and efficiently), review of equipment, etc. Copyright 2014-PEC Safety 13 2014 Standardized Safety Questionnaire
66b. If Yes above, are some or all of the JSAs pre-populated? JOB SAFETY ANALYSIS (JSA) 66c. If Yes above, do you or your company require employees to obtain approval by the person in charge on all JSAs? 66d. If Yes above, are site specific hazards addressed in the JSAs? 66e. If Yes above, are environmental concerns addressed in the JSAs? 66f. If Yes above, are safety concerns addressed in the JSAs? 66g. If Yes above, are equipment requirements for the job reviewed and documented in the JSAs? 66h. If Yes above, do all employees involved with the job participate in the JSAs? 66i. If Yes above, do you or your company update JSAs to ensure that they are consistent with the current operations at the facility? 66j. If Yes above, do you or your company have policies in place to communicate changes in the JSAs? 66k. If Yes above, do you or your company provide JSA training to the company s employees? 67. If required by your Operator and you have purchased the Document Upload & Adv Training Tracker Bundle or CAP package, please use the following link to upload your company s last completed JSA. Click here to view the uploaded JSA Note: If you are uncertain whether or not this is required by the PEC Member Operator(s) you work for, please review the Operators notification letter(s) received or contact PEC Customer Support at 866-647-2338. 68. Do you or your company have a written hazard identification process that identifies hazards in order to plan for, avoid, or mitigate their impacts? 69. Do you or your company have a written stop work authority providing employee s authority to stop work when an unsafe condition or act is observed that could affect the safety of the personnel and/or the environment? MECHANICAL INTEGRITY 70a. Do your or your company provide any critical equipment on Operator(s) premises? Definitions: Mechanical Integrity To ensure equipment does not fail in any way that causes or affects a release of highly hazardous chemicals. Equipment is the hardware that helps contact the chemicals in the process. It covers the proper design, fabrication, construction/installation, and operation of equipment throughout the entire process life cycle. Critical Equipment- Equipment and other systems determined to be essential in preventing the occurrence of or mitigating the consequences of uncontrolled release. Such equipment may include vessels, machinery, piping, blowout preventers, wellheads and related valving, flares, alarms, interlocks, fire protection equipment and other monitoring control response systems. Copyright 2014-PEC Safety 14 2014 Standardized Safety Questionnaire
MECHANICAL INTEGRITY (CONTINUED) 70b. If Yes above, do you have a written mechanical integrity plan? 70c. If Yes above, does your written mechanical integrity plan address the critical equipment used on Operator(s) premises? 70d. If Yes above, does your written mechanical integrity plan ensure the mechanical integrity and safe operation of equipment through inspection, testing and quality assurance? 70e. If Yes above, do you document inspections, maintenance and repairs as part of your mechanical integrity plan? 70. If Yes above, does your written mechanical integrity plan address the following: f. Manufacturing/Fabrication Yes No N/A g. Engineering and Design h. Commissioning/Installation i. Startup Review j. Operations and Procedures k. Maintenance l. Repair/Rebuild 70m. If Yes above, does your written mechanical integrity plan also apply to equipment that does NOT prevent or mitigate uncontrolled releases of hydrocarbons, toxic substances, or other materials, but could potentially result in either personal injury or in an environmental release? See the note below for an example. NOTE: For example: The inspection and repair of grinding equipment to ensure it has proper guards. 71. If required by your Operator and you have purchased the Document Upload & Adv Training Tracker Bundle or CAP package, please use the following link to upload the most recent copy of your company s Mechanical Integrity Plan policies and procedures. Click Here to Upload Your Mechanical Integrity Plan NOTE: If you are uncertain whether or not this is required by the PEC Member Operator(s) you work for, please review the Operators notification letter(s) received or contact PEC Customer Support at 866-647-2338. COMMUNICATIONS 72a. Do you or your company have any non-english speaking employees in your workforce? 72b. If Yes above, are language barriers addressed in your Environmental, Health, and Safety (EHS) programs? 72c. If Yes above, then what is the common language(s) other than English? 72d. If Yes above, do you or your company have your EHS programs written in the language(s) listed above? Copyright 2014-PEC Safety 15 2014 Standardized Safety Questionnaire
73a. Have you or your company had any incident(s) where a causal factor was a language barrier issue? COMMUNICATIONS (CONTINUED) 73b. If Yes above, please describe what was done to address the language barrier causal factor? DRUG AND ALCOHOL PROGRAM 74a. Do you or your company have a written Drug and Alcohol testing program which prohibits the misuse of prescription medications and the use, possession, or sale of illicit drugs or alcohol? 74b. If Yes above, does your company have a Zero Tolerance Drug & Alcohol Policy? 75a. Do you or your company have a Drug and Alcohol Program Manager? 75b. If Yes above, is the manager trained on program compliance? 76. Do you or your company receive all drug tests (not pending) prior to anyone from your company starting work? 77a. Are you or your company a member of a consortium? NOTE: A Drug and Alcohol Consortium is defined as a group of companies formed to undertake drug and alcohol testing. 77b. If Yes above, what is the name of the consortium to which you or your company belongs? 78. Do you or your company understand that your personnel are subject to Drug and Alcohol search provisions including post incident and reasonable suspicion testing while working on Operator(s) premises? 79. Indicate the circumstances in which your company s employees may be subject to drug screening. a. Pre-employment b. Periodic/Scheduled c. Post-accident d. Probable Cause/Reasonable Suspicion e. Random f. On Return to Duty Yes No Copyright 2014-PEC Safety 16 2014 Standardized Safety Questionnaire
FINES AND CITATIONS 80. Have you or your company received any citations or fines from a regulatory agency since January 1, 2012? 81. If Yes above, indicate which agencies and how many citations or fines for each agency your company has received since January 1, 2012. Regulatory Agency Citation or Fine? USCG a. b. Yes No How Many? BSEE c. d. BLM e. f. EPA g. h. OSHA i. j. DOT-Trucking k. l. DOT Pipeline m. n. OTHER o. p. Name of OTHER Regulatory Agency q. 82. Above you indicated your company has received OSHA citations and/or fines. Please indicate the Violation Types of your OSHA citations and/or fines. Check all that apply. Violation Types Check Violation Types Check Serious Repeat Other Unclassified Willful NOTES: You can use the OSHA Fines and Citations Helpful Link at the top of this page to look up your company on OSHA s website which will show you the violation types of your company s fines and citations. For more information on the five possible types of OSHA violations, please refer to the OSHA Violation Types Helpful Link. Additionally, you must provide the specific details of your citations and fines in the next question below. 83. Above you indicated your company has received OSHA citations and/or fines. Please provide details of each of your OSHA citation(s) and/or fine(s) in the space below. 84a. If Yes above, have all issues been resolved with the regulatory agency(s)? 84b. If "No" above, please provide details of each citation or fine incident that has not been resolved. Copyright 2014-PEC Safety 17 2014 Standardized Safety Questionnaire
INCIDENT PROCEDURES 85. Do you or your company conduct or participate in routine emergency drills? 86a. Do you or your company conduct documented accident/incident investigations? 86b. If Yes above, do these investigations include spills, injuries, property damage, near misses, fires, explosions, etc.? 86c. If Yes above, are the documented accident/incident reports reviewed by managers/supervisors? 87. Do you or your company have a written process to track accident/incident investigation corrective action findings to closure? 88. Do you or your company have a written process to share the lessons learned from accidents/incidents with the entire workforce? 89a. Do you or your company have a written policy that describes roles and responsibilities that will be initiated in the event of an accident? 89b. If Yes above, is your company s written policy communicated so all employees understand you or your company s position? 89c. If Yes above, does your written policy require an authorized individual to accompany injured employees to the medical provider for initial treatment? 90. Do you or your company have a written Restricted Duty/Light Duty policy? 91a. If Yes above, does your company utilize a specific medical provider that understands your company s Restricted Duty / Light Duty policy? 92. On large projects, does your company employ a paramedic, nurse, or physician with occupational medicine experience at the worksite? INDUSTRIAL HYGIENE OCCUPATIONAL HEALTH 93. Do you perform Industrial Hygiene monitoring on your employees? 94. If Yes above, please indicate for which substances do you or your company provide IH monitoring in the list below. a. Asbestos Yes No N/A b. Benzene c. Lead d. Radiation e. Silica f. Total Hydrocarbons Copyright 2014-PEC Safety 18 2014 Standardized Safety Questionnaire
INDUSTRIAL HYGIENE OCCUPATIONAL HEALTH (continued) g. Welding Fumes h. Other Substance(s) i. Please list the Other substance(s): 95a. If Yes above, where are industrial Hygiene monitoring records kept? (Example: location/address of office, name of online service, etc.) 96a. Do you or your company have a written hearing conservation program? 96b. If Yes above, does the written hearing conservation program include audiometric testing? 97a. Do you or your company have a respiratory protection program? 97b. Do you or your company have employees who wear (Canister or SCBA) respirators? 97c. If Yes above, are your company s employee respirators medically cleared? 97d. If Yes above, are your company s employee respirators annually fit tested? 98. Do you or your company conduct fitness for work exams for any of the following? a. Audiograms Yes No N/A b. Pre-employment c. Re-employment d. Respiratory Yes No N/A e. DOT Physical f. Visual g. OTHER h. Please list Other fitness for work exams: Copyright 2014-PEC Safety 19 2014 Standardized Safety Questionnaire
MANAGEMENT OF CHANGE (MOC) 99a. Do you or your company have a written Management of Change process/program as described below, as it pertains to Safety and Environmental Management Systems (SEMS) and/or Process Safety Management (PSM)? Management of Change (MOC) is a process to trigger a formal evaluation of possible safety, health, or environmental hazards brought on by temporary and/or permanent changes related to personnel/technical functions within your organization. 99b. If Yes above, does your written management of change process cover changes in key personnel? 99c. If Yes above, does your written management of change process cover changes in technical aspects of the job? 100. If required by your Operator and you have purchased the Document Upload & Adv Training Tracker Bundle or CAP package, please use the following link to upload your company s Management of Change Plan. Click Here to Upload Your Management of Change Plan NOTE: If you are uncertain whether or not this is required by the PEC Member Operator(s) you work for, please review the Operators notification letter(s) received or contact PEC Customer Support at 866-647-2338. PERSONAL PROTECTIVE EQUIPMENT 101. Do you or your company have a written Personal Protective Equipment (PPE) program? (OSHA 29 CFR 1910.132) 102. Indicate which of the following personal protective equipment your company provides/requires: Personal Protective Equipment (PPE) Company Provided Company Required Yes No N/A Yes No N/A Eye Protection (ANSI Z87.1)(29 CFR 1910.133) a. b. Fall Protection (29 CFR 1915.159) c. d. FRC Fire Retardant Clothing (BEST PRACTICES) e. f. H 2 S Personal Alarm Monitors Hand Protection (29 CFR 1910.132) Hard Hats (ANSI Z89.1)(29 CFR 1910.135) Hearing Protection (29 CFR 1910.95) Personal Flotation Devices (33 CFR 142.45) Respiratory Protection (29 CFR 1910.134) Safety Shoes (ANSI Z41.1) (29 CFR 1910.136) g. h. i. j. k. l. m. n. o. p. q. r. s. t. Copyright 2014-PEC Safety 20 2014 Standardized Safety Questionnaire
PERSONAL PROTECTIVE EQUIPMENT (CONTINUED) 103. In addition to regulatory required Personal Protective Equipment, what other PPE is required or supplied? If any, please describe or list: 104a. Do you or your company perform inspections on PPE? OSHA 29 CFR 1910.132 (e) 104b. If Yes above, do you or your company maintain PPE inspection records? OSHA 29 CFR 1910.132 (e) 105. Do you or your company perform PPE hazard assessments to identify workplace hazards? OSHA 29 CFR 1910.132 (d)(2) QUALITY ASSURANCE QUALITY CONTROL 106. Do you or your company have a Quality Assurance/Quality Control Department? 107. Do you or your company have a written Quality Assurance/Quality Control policy? 108a. Do you or your company utilize your own equipment? 108b. If Yes above, do you or your company have a written preventative maintenance program for company owned equipment? 109a. Do you or your company utilize rental equipment? 109b. If Yes above, do you or your company have a written preventative maintenance program for rental equipment? 109c. If Yes above, does the preventative maintenance program for rental equipment require previous maintenance records for the rental equipment? 110. If Yes above, do you or your company s preventative maintenance program require previous maintenance records for the equipment your subcontractors use on Operator(s) premises? 111a. Do you or your company keep preventative maintenance and equipment inspection records on file? 111b. If Yes above, where do you keep the maintenance records? (example: Office address, name of online service) Please include company owned, rented, subcontractors, etc. 112. Do you or your company conduct inspections on operating equipment, such as Cranes, Forklifts, etc.? Copyright 2014-PEC Safety 21 2014 Standardized Safety Questionnaire
ONSHORE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION (FMCSA) 1a. Is your company exempt from the Federal Motor Carrier Safety Administration (FMCSA)? 1b. If No above, meaning your company is not exempt from FMCSA, please provide your company s DOT number. 1c. If No above, meaning your company is not exempt from FMCSA, what type of carrier is your company? 1d. If No above, meaning your company is not exempt from FMCSA, then does your company maintain driver qualification files? 1e. If No above, meaning your company is not exempt from FMCSA, then does your company maintain an Accident Register? ADDITIONAL QUESTIONS 2. Do you or your company s drug and alcohol testing program conform to DOT requirements? 3. Indicate which set of DOT regulations your drug-testing program satisfies below: a. Federal Aviation Administration 14 CFR, Part 91.17 Yes No N/A b. Federal Highway Administration 49 CFR, Part 382, Part 392 c. Federal Railroad Administration 49 CFR, Part 219 d. Pipeline and Hazardous Materials Safety Administration Pipeline 49 CFR, Part 199 4. Do you or your company have a policy / best practices on electronic devices (such as PDA, computer, cell phones, etc.) usage while operating a motor vehicle? 5. What safety equipment do you maintain in your company vehicles? a. Safety Equipment b. Spill Kits (Can be Shovels, Buckets, Absorbents, as it Pertains to Work) c. MSDS (EHS Material Safety Data Sheet) d. Eye Wash e. First Aid Kit f. Blood Borne Pathogen Clean Up Kit 6. Do you or your company conduct fitness for work exams for DOT physical? Yes No Copyright 2014-PEC Safety 22 2014 Standardized Safety Questionnaire
ADDITIONAL QUESTIONS (CONTINUED) 7. Are you or your company required to have any Federal, State, or local licenses or permits to perform their service(s)? NOTE: Examples: NORM, Asbestos, DOT, Lead, Explosives, ets 8. If Yes above, list the agency name, state of issue, and liscense or permit types below: Agency State Issued License or Permit Type a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. PROCESS SAFETY MANAGEMENT (PSM) 9. Do you or your company perform services inside a Process Safety Management (PSM) facility? OFFSHORE This section is required for companies that have selected the Domestic USA Offshore Oil and Gas Service Region. This section is intended for companies that perform offshore work. If your company does not perform offshore work, please navigate to the Services section using the dropdown list at the bottom of this page and remove Domestic USA Offshore Oil and Gas from the list box labeled Regions Currently Serviced by this Company. 1a. Do you or your company perform work involving Production Safety Systems (PSS) covered by 30 CFR 250 Subpart O? 1b. If Yes above, how do you or your company verify that your employees (and/or contract personnel) engaged in PSS understand and can properly perform their duties? 1c. If Yes above, what are your procedures for assessing the PSS training needs of your employees on a periodic basis? 1d. If Yes above, do you or your company have a written training program for those personnel who perform Production Safety Systems (PSS) activities? 1e. If Yes above, is your training program API RP T2 certified? 1f. If No above, what equivalent training program are you using? 2a. Do you or your company perform work involving related well control activities covered by 30 CFR 250 Subpart O? 2b. If Yes above, how does your company verify that your employees (and/or contact personnel) engaged in well control activities understand and can properly perform their duties? Copyright 2014-PEC Safety 23 2014 Standardized Safety Questionnaire
OFFSHORE (CONTINUED) 2c. If Yes above, what are your procedures for assessing the well control training needs of your employees on a periodic basis? 2d. If Yes above, do you have a written training plan for those personnel who perform well control activities? 2e. If Yes above, does your training plan for well control activities include hands-on training? 2f. If Yes above, is your training accredited by IADC as following WellCAP requirements? 2g. If No above, what equivalent training program are you or your company using? 3a. Do you or your company perform wireline work, either slickline or electronic wireline? 3b. If Yes above, how do you or your company verify that your employees (and/or contract personnel) engaged in wireline related well control understand and can properly perform their duties? 3c. If Yes above, what are your procedures for assessing the wireline related well control training needs of your employees on a periodic basis? 3d. If Yes above, do you have a written training plan for those personnel who perform wireline related well control duties as defined in 30 CFR 250 Subpart O? 3e. If Yes above, is your training program API RP T6 and/or IADC WellCAP for Wireline certified? 3f. If No above, what equivalent training program are you using? 4a. Do you or your company have offshore crane operators? 4b. If Yes above, do your offshore crane operators have API RP 2D physical requirements and have documented evidence they meet these requirements? SAFETY ENVIRONMENTAL MANAGEMENT SYSTEM (SEMS) OFFSHORE Offshore Operators asked that the Offshore SEMS section remain isolated. Therefore, some of the questions are repeated in other sections. You will only have to answer questions once as your answers will populate repeat questions. Repeat questions can be found in the following sections: Training Questions Section, Safety Meetings/JSA/Mechanical Integrity Section and Management of Change Section. 5a. Do you or your company's employees or subcontractor(s) perform work on or at an offshore facility / lease site under the jurisdiction of the Bureau of Safety and Environmental Enforcement. (BSEE) NOTE: Offshore SEMS contractor definition (from Center for Offshore Safety): The individual, partnership, firm, or corporation retained by the owner or operator to perform work or provide supplies or equipment. The term Contractor for Center of Offshore Safety includes subcontractors. If you fall into this Contractor category and feel like you received this section in error, return to the Services Section of this questionnaire and only choose US Domestic Onshore. Copyright 2014-PEC Safety 24 2014 Standardized Safety Questionnaire