CONTRACTOR SAFETY MANAGEMENT PROGRAM (CSMP) PRE-QUALIFICATION SAFETY QUESTIONNAIRE Omitting or reporting false information on this questionnaire could result in disqualification or removal from the Supplier Information Database. SRP reserves the right to conduct random or for-cause audits of information stated in this questionnaire. Additional documentation may be requested by SRP to support statements made on the questionnaire. Company name Address City State ZIP Code Web address Name (please print) Title Telephone number Email address Signature Date Name of the SRP Purchasing person you are working with (this must be filled out in order to process your questionnaire properly) THIS SECTION FOR SRP USE ONLY: Requested by: Submitted by: SRP vendor # Date: Date: Scored by: Date: CSMP score: Date: x63-021 03/17
SAFETY SERVICES SAFETY MANAGEMENT STATEMENT At SRP, safety is a fundamental core value. SRP and its employees are committed to conducting all business and operations with the highest regard for the safety of employees, contractors, customers and the public. SAFETY GOALS Conduct business in a responsible manner that promotes the safety, health and well-being of our employees, our contractors and the public. Provide a safe and healthful work environment free from recognized hazards. Strive to prevent all work-related injuries, occupational illnesses and property damage. Regularly evaluate our safety performance to ensure that we continually meet or exceed all safety, health and environmental regulations. Investigate incidents, incorporate lessons learned and communicate findings to affected employees. KEY PRINCIPLES OF SAFETY MANAGEMENT Safety is the responsibility of both management and employees. Management is committed to a safe and healthful work environment. Management is committed to visible involvement in the safety of employees. Management is responsible for ensuring that workers are encouraged to report hazards, symptoms, injuries and illnesses. Supervisors are responsible for providing safety training, equipment and materials and ensuring employees compliance with all safety procedures, rules and regulations. ALL employees are responsible and accountable for working safely and actively caring for and committing to each other s safety. General Manager & CEO President 12-1245-01 09/12
CONTRACTOR PRE-QUALIFICATION SAFETY QUESTIONNAIRE IMPORTANT This form MUST be completed in full and all requested documentation must accompany the questionnaire upon submission. Failure to submit in full may prevent the company from being considered as a potential service contract provider until a complete form has been submitted. Company/Safety Representative Name Title Mailing address City State ZIP Code _ Telephone number Email address _ Please select the appropriate level for which you are reporting information. Be sure to include the total number of individuals currently employed at your company. The following information is: No. of employees Corporate Subsidiary Local State National 1
A SAFETY HISTORY 1. EXPERIENCE MODIFICATION RATE (EMR) Please contact your insurance carrier to determine and validate the following requested EMR information responses before submitting to SRP. Please be prepared to show a certified letter that includes the EMR data for the current year and each of the previous three (3) calendar years. Provide Workers Compensation EMR for your company for the current year and each of the previous three (3) calendar years as determined by the NCCI. Year EMR Comments Current 2. OSHA NON-COMPLIANCE CITATIONS List the number of upheld OSHA Non-Compliance Citations received in the current year and each of the previous three calendar years. Provide an explanation of the nature of each citation in the space provided. Year No. citations upheld Please explain (attach additional sheets if needed) Current 3. OSHA SAFETY INFORMATION Provide data for the current year and each of the previous three (3) calendar years. NOTE: Most of this information is available on your company OSHA 300A Summary. Current year 3 previous calendar years No. of months Total employee hours worked Total number of OSHA recordable injury/illness cases Total number of lost-time injury/illness cases Total days away from work due to injury/illness 2
4. NUMBER OF FATALITIES Please enter the number of fatalities experienced for the current year and the previous three calendar years in the spaces provided. Please enter a brief explanation for each fatality in the space provided below: (Attach additional sheets as needed.) Current year 3 previous calendar years No. of months: Number of fatalities: B SAFETY AND HEALTH PROGRAMS 1. Does your company have a substance abuse screening program? Yes No If yes, does your program include: Pre-hire screening testing? Yes No Post-accident testing? Yes No Random testing? Yes No 2. Does your company have a written occupational safety and health program? Yes No (This may be part of a company operational program or human resources program used to provide employees with safety awareness, rules and expectations, i.e., safety policies, procedures and guidelines employees are required and/or expected to follow while employed with your company.) 3. Do your work crews conduct daily pre-work job briefings (tailboards) before the start of each shift/job? Yes No 4. Does your company conduct driver s license record verification for every employee required to operate a company vehicle on the job? Yes No If yes, please indicate the frequency and type of verification performed below. Please select all that apply: Upon Hire Annual Random Accident Occurrence/Other 3
C CERTIFICATIONS AND SPECIALTY TRAINING 1. Does your company document employee specialty certifications for specific trades, equipment or job functions? Yes No Select all that apply: Trade Safety CDL/ Vehicle Operations Material Handling Equipment (forklift/crane/other) If not listed above, please enter in the space provided below. Additional Certifications 2. Have any of your employees completed OSHA 500 or OSHA 501 training? Yes No Comments: 3. Have any of your employees completed OSHA 10-hour or OSHA 30-hour training? Yes No Comments: 4. Please list additional safety-related training provided to your employees, by type and frequency, in the space provided below: (Attach additional sheets as needed.) ADDITIONAL INFORMATION Please provide any additional information not previously disclosed during completion of this questionnaire that may assist in the SRP CSMP safety review and scoring process in the space provided below: (Attach additional sheets as needed.) 4