Dear contractor; The Health & Safety of our employees and you our contractor is of utmost concern and importance to Hulcher Services Inc. Hulcher Services is building a strong base of independent contractors who are contracted for their unique skills and expertise. Our contractors work hard to ensure that their employees are safe while performing work for at our sites. While Hulcher Services Inc. injury rates have been trending downward, the incidence of serious injuries involving our contractors still exists, and based on that potential, it is important for not only our employees but also our contractors to understand that any incident that causes harm to an individual working or present at any of our sites, or damages sustained by equipment or to third parties, is unacceptable. As an employer or as a contractor representing Hulcher Services Inc., you are required to comply with all applicable Occupational Safety and Health Administration regulations, Federal Railroad Administration regulations as well as any site specific, state, local requirements pertinent to the Health and Safety of your employees including. Working for Hulcher Services Inc. specifically requires that you provide all necessary health & safety training and personal protective equipment to your employees before those employees can perform any work at any of our job site locations. In addition, any subcontractor brought in under your supervision is required to acknowledge your health & safety responsibilities as prescribed in your contract as well as to meet or exceed the qualifications required by our company in order to perform work for or on our behalf. Infractions of Hulcher Services Inc. safety policies and legal requirements, including those established by our customers may result in contract termination or loss of future business for all parties involved. Your employees including those subcontracted by you who violate these rules and pose risks to themselves or others at any of our sites, whether directly or indirectly supervised by a Hulcher Services management team member, maybe banned from working in our divisions or job sites. Basic violations of injury, fatality, equipment damage prevention rules will not be tolerated and will be handled with a ZERO tolerance approach. Finally, Hulcher Services is initiating a mission; The Hulcher Contractor Safety Management Process (HCSMP) which was developed to address the need of assuring incident free work sites on Hulcher projects and to improve the safety of its employees, contractors, subcontractors, visitors, and general public. Please acknowledge receipt of this letter and your shared responsibilities for ensuring the safety and health of your employees at our worksites by having an authorized representative of your company sign this document. If you have specific questions related to this letter, please contact Rafael Colmenares, Assistant Director of Health & Safety, at rcolmenares@hulcher.com Thank you for your efforts and commitment to a safe incident free workplace. Signature Date Page 1 of 7 Revision 2 7/29/13
SUBCONTRACTOR SAFETY QUALIFICATION FORM Company Name: NAICS / SIC #: Address: Type of Business: Type of Services provided to Hulcher: Contact Person: Phone # : Email: Title: PART I: CONTRACTOR S SAFETY PROFILE Listed below are questions to be used to determine your company s overall safety performance. It focuses on and describes your organization s present business approach towards safety. 1. Do you currently have a written health and safety program in full force and effect? please attach a copy of the table of contents 2. Do you have a designated safety professional? If no, do you have a designated person responsible for Health and Safety in your organization? Name: Title: 3. Does your company provide drug/alcohol screening? Random DOT Post Incident Pre employment Page 2 of 7 Revision 2 7/29/13
4. Are regular safety meetings held at sites? are records available? Please list frequency: 5. Are new employees provided with safety orientation? 6. Please check the following personal protective equipment that your company requires employees to use on sites: Hard hats Eye Protection (including goggles/faceshields) consistent with hazards at sites Safety toed boots Safety Vests Hearing Protection 7. Does your company provide safety training for field personnel? Please check if the following training is provided and list the frequency in which the training is administered: Equipment Operation Defensive Driving On Track Safety Hazard Recognition PPE Is the training provided by: Internal trainer Outside trainer Is safety training documentation available? Page 3 of 7 Revision 2 7/29/13
8. Does your company perform scheduled inspections and maintenance on equipment and safety devices? Frequency Page 4 of 7 Revision 2 7/29/13
SUBCONTRACTOR SAFETY QUALIFICATION FORM PART II: CONTRACTORS SAFETY PERFORMANCE INDEX Listed below are questions to be used to determine your company s overall safety performance metrics. Number of employees full time Number of employees part time DOT NUMBER: OSHA 300A SAFETY INFORMATION: (required if you have more than 10 employees) 20 20 20 A. Total Number of OSHA Recordable Incidents *B. OSHA Recordable Incident Rate C. Number of Lost Time Incidents/Illnesses *D. Lost Time Incident Rate E. Number of days away from work F. Number of Fatalities G. TOTAL EMPLOYEE HOURS WORKED *Note: for B and D Rates use the formula: Number of Incidents (A or C) multiplied by 200,000, and then divided by # of employee hours worked. (Attach copies of OSHA 300/300A logs most recent 3 years) EXPERIENCE MODIFICATION RATE (EMR) (provided by your insurance carrier) List your worker s compensation EMR for the most recent 3 years. (Attach a copy of EMR letter) 20 20 20 Corporate: 1. Within the last two years, has your company received ANY citations (open or closed) for OSHA defined REPEAT violation(s) in any state where your company operates? attach a copy of each citation Page 5 of 7 Revision 2 7/29/13
2. Within the last two years, has your company received ANY citations (opened or closed) for OSHA defined WILLFUL violation(s) in any state where your company operates? attach a copy of each citation 3. For any state where your company operates: a. Has your company experienced any work related fatality within the last five years? Any citations (opened or closed) issued by OSHA as a result of the work related fatality? attach a copy of each citation. Please include a statement explaining each fatality you identified. 4. Within the last three years has you company received any citations by the Department of Transportation? attach a copy of each citation For Internal Use Only Contractor s Safety Performance Score: PART I Safety Performance Profile: (Maximum of 10 points) PART II Safety Performance Index : ( Maximum of 90 points) Contractor s Safety Performance Total Score: A+ 100, A 90 99, B 80 89, C 70 79, D 60 69, F <59 Unsatisfactory Page 6 of 7 Revision 2 7/29/13
Affidavit I hereby certify that all of the information in this application is correct to the best of my knowledge. I also certify that our company will at all times comply with Hulcher Services requirements in order to remain on the Hulcher Services list of Prequalified Contractors. Company Name: By: (Signature of Officer of Company) Officer s Title: Date: Page 7 of 7 Revision 2 7/29/13