"CONTRACTORS SAFETY PRE-QUALIFICATION QUESTIONNAIRESURVEY"
CONTRACTORS SAFETY PRE-QUALIFICATION QUESTIONNAIRE/SURVEY Citizens Gas is committed to providing a safe workplace for employees, contractors and the general public. To qualify to perform on-site work, Citizens Gas contractors must provide the following information and agree to obtain the following information from all subcontractors utilized and provide it upon request. Contractor/Company Name: ___________________________________________________ Date:____________________________ Contracted Ativity:_____________________________________________________________________________________________ Contractor Representative:___________________________________ Phone#:____________________________________________ Contractor Address:____________________________________________________________________________________________ Signature:____________________________________________________________________________________________________ 1. In the table below, provide the three most recent full years of history for the area or region to which this questionnaire applies. In addition, attach copies of applicable OSHA 300 logs and verification of your EMR/discount rate information. ITEM DESCRIPTION 20___ 20___ 20___ A Interstate Experience Modification Rate (EMR) B Total recordable Incident Rate C Lost Time Incident Rate Using the OSHA #300 logs from the facility providing labor, please document the following: D Number of Injuries and Illnesses ______ ______ ______ E Number of Lost Workday Cases ______ ______ ______ F Number of Injury Related Fatalities ______ ______ ______ G Total Number of Employees H Employee hours Worked Per Year (if unknown use # of employees x 2080) *(B) Rate = D x 200,000 / H *(C) Rate = E x 200,000 / H GENERAL 1. Does your company have a written safety and health program? Yes___ No___ Written Hazard Communication Program? Yes___ No___ 2. Does your company use subcontractors? Yes___ No___ If yes, do you qualify subcontractors based on their ability to address safety, health and environmental requirements? Yes___ No___ Do you verify that they meet regulatory requirements? Yes___ No___ Do you have a formal contractor safety program? Yes___ No___ 3. Are all documents, pertaining to this questionnaire, available for auditing? Yes___ No___ If no, please explain: _____________________________________________________________________ 4. Who in your company coordinates your safety and health program? Name/Title: _____________________ Phone#:_________ 5. Has your company received any citations from a regulatory agency during the last three years? Yes___ No___ If yes, please describe citations: _____________________________________________________________ (Okay to use additional paper, if needed.) 6. Does your company perform Job Safety Analysis (JSA)? Yes___ No___ 7. Do all new employees complete a safety orientation before performing any work activities? Yes___ No___ 8 Do you require the OSHA 10-hour course for all supervisors? Yes___ No___ 9. Are accident/incident reports received by managers/supervisors? Yes___ No___ AUDITING 1. Does your company perform safety audits/reviews? Yes___ No___ If yes, are safety audits documented? Yes___ No___ 2. Who performs the safety audit/review and how often? Title:______________________________________ PERSONAL PROTECTIVE EQUIPMENT 1. Does your company require the following: Hard Hats (ANSI-Z89)(29 CFR 1910.135) NA___ Yes___ No___ Safety Shoes (ANSI-Z41)(29 CFR 1910.136) NA___ Yes___ No___ Eye Protection (ANSI-Z87)(29 CFR 1910.133) NA___ Yes___ No___ Hand Protection (29 CFR 1910.132) NA___ Yes___ No___ Hearing Protection (29 CFR 1910.95) NA___ Yes___ No___ Fall Protection (29 CFR 1926.500) NA___ Yes___ No___ Respiratory Protection (29 CFR 1910.134) NA___ Yes___ No___ 2. In addition to regulatory required Personal Protective Equipment, what other PPE is required or supplied? If any, pleas describe or list: ______________________________________________________________ SAFETY MEETINGS 1. Does your company have scheduled, documented employee safety meetings? Yes___ No___ If yes, how often? ______________________________________________________________________ 2. Who conducts the safety meetings? Job Title: ________________________________________________ 3. Do managers/supervisors participate in the safety meetings? Yes___ No___ 4. Does your company hold work-site (tailgate) safety meetings? Yes___ No___ If yes, how often? ______________________________________________________________________ 5. Who conducts these safety meetings? Title;_________________________________________________ 6. Is documentation of safety meetings available? Yes___ No___ DRUG SCREENING OR TESTING 1. Does your company have a written policy regarding drug screening or testing of employees? Yes___ No___ 2. Does your drug testing program conform to DOT requirements? Yes___ No___ If yes, which DOT regulations is your program designed to satisfy? Research and Special Projects Administration – Pipeline Yes___ No___ Federal Highway Administration Yes___ No___ 3. Indicate the circumstances in which your company’s employees may be subject to drug screening. Employment Probable Cause Periodic Random Post Accident Other____________ 4. Do you have a mandatory substance abuse program? Yes___ No___ ACCIDENT/INCIDENT INVESTIGATIONS 1. Does your company have policy requiring written accidents/incident reports? Yes___ No___ 2. Does your company conduct accident/incident investigating? Yes___ No___ 3. Do you conduct jobsite safety inspections? Yes___ No___ 4. Do you have a light duty/restricted work policy? Yes___ No___ 5. Do you conduct documented post accident investigations? Yes___ No___ TRAINING Please respond to the following items with “Yes, No or N.A.” (Estimated percentage of Employees should reflect the percentage of employees providing labor who have received training). PROGRAMS/TRAINING Reference Source Program is Estimated % of Frequency of Individual documented employees training for employee and written providing individual training Yes/No/NA services who employees documented have received Yes/No/NA training Asbestos Class IV (awareness) OSHA 29 CFR 1926-1101 Asbestos Class III OSHA 29 CFR 1926-1101 Asbestos Class I and II OSHA 29 CFR 1926-1101 Confined Space Entry OSHA 29 CFR 1910.146(g) Cranes OSHA 29 CFR 1926 DOT HM-126\f Hazmat Employee DOT 49 CFR 172.704 Drug Awareness DOT 46 CFR 16.401 & 391.119 Electric Power Gen, Tran, Dist OSHA CFR 29 1910.269 Electrical Safety OSHA CFR 29 CFR 1910.332 Emergency Response OSHA 29 CFR 1910.38(a) Excavations OSHA 29 CFR 1926.651 Fall Protection OSHA 29 CFR 1926.500 First Aid/CPR OSHA 29 CFR 1910.151(b) Forklifts OSHA 29 CFR 1910.178(1) HAZCOM OSHA 29 CFR 1910.120(h) Hazwoper-Awareness Level OSHA 20 CFR 1910.120 Hazwoper 8 Hour OSHA 29 CFR 1910.120 Hazwoper 24 Hour OSHA 29 CFR 1910.120 Hazwoper 40 Hour OSHA 29 CFR 1910.120 Hazwoper Supervisor 8 Hours OSHA 20 CFR 1910.120 Hearing Conservation OSHA 29 CFR 1910.95 Incipient Fire Fighting OSHA 29 CFR 1910.157(g) Lead Worker OSHA 29 CFR 1926.62 (T) Lead Supervisor See Above Lockout/Tagout Authorized Person OSHA 29 CFR 1910.147 (c)(7) Lockout/Tagout Affected Person See Above New Employee Orientation OSHA 29 CFR 1910.119 (g)(1) Personal Protective Equipment OSHA CFR 1910.132(f) Process Safety Management OSHA 29 CFR 1910.119(g)(1) Respiratory Protection OSHA 29 CFR 1910.134(e)(5) Welding and Burning OSHA 29 CFR 1910.252(a)(2)(xii)(c) Scaffolding OSHA 29 CFR 1926.451 Please send this completed form to: Jeff Ford Director of Purchasing Citizens Energy Group 2020 N Meridian St Indpls, IN 46202