SUBCONTRACTOR SAFETY QUALIFICATION FORM Company Name: NAICS / SIC #: Address: Type of Business: Type of Services provided to Hulcher: Contact Person: Phone # : Email: Title: Date: 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