Bowen Supplier Pre-Qualification 06-2010 by ashrafp

VIEWS: 5 PAGES: 19

									        Prequalification Surveys and all supporting documentation must be completed by an
        Authorized Representative of the company.

        The undersigned certifies that the information provided herein is a clear and accurate
        representation of this organization.



        Signed by:

              ___________________________                                  _________________________
        Print Name                                                 Title




        _______________________________                                    _________________________
        Signature                                                  Date




8802 North Meridian Street • Indianapolis, IN 46260 • 317.842.2616 phone • www.BowenEngineering.com
                         Contractor Financial Pre-qualification Survey


Company’s Legal Name:

Street Address:

City, State, and Zip:

Controller:               Telephone:         Fax:

Email Address:

Additional Financial Contact:          Telephone:         Fax:

E-Mail Address:                   Title:

Company’s Web Address:


Select One:                       State of Formation:               Date Founded:
      Corporation
      Partnership                 Select (if applicable):
      Individual                         MBE              SB           SD-VOSB         SDB
      Joint Venture                      WBE              VOSB         HUBZone         WOSB
      Other                              DBE              SDB


List the company’s Key Officers and Members legally authorized to execute documents.
   Name:                           Title:
   Name:                           Title:
   Name:                           Title:
   Name:                           Title:
   Name:                           Title:
   Name:                           Title:




                                                    A-1
Attachment A


1.   Has the company ever failed to complete any work awarded to it?         Yes          No
         If yes, please explain:

2.   Is the company’s Labor force?     Union        Non-Union

3.   Has the company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted, or been
     terminated on a contract awarded?       Yes       No
         a. If yes, please explain.

4.   Have any of the owners, officers or major stockholders of the company ever been indicted or convicted of any
     felony or other criminal conduct?    Yes        No
         a. If yes, please explain.

5.   Has the company or any of the owners, officers or major stockholders ever been suspended, disbarred or
     otherwise precluded from pursuing public work or ever been found to be non-responsive to a public agency?
             Yes        No
         a. If yes, please explain.

6.   Has the company ever had a claim made against it for improper, delayed, defective or non-compliant work or
     failure to meet warranty obligations? Yes          No
          a. If yes, please explain.

7.   Is the company or any of the owners, officers or major stockholders currently involved in any arbitration or
     litigation?    Yes         No
           a. If yes, please explain.

8.   Does the company have any outstanding judgments or claims against it?          Yes            No
        a. If yes, please explain.

9.   Has the company or any of the owners, officers or major stockholders ever been investigated for, or charged with,
     alleged labor law violations including alleged violations of Immigration Control and Reform Act; state or local laws
     regarding employment of immigrants; prevailing wage laws; wage and hour laws or other federal, local or state
     labor laws?     Yes        No
          a. If yes, please explain.

10. Please provide the following information for the last three years and current year-to-date.

                                                                        DEBT TO EQUITY                NET
               # OF                            CURRENT RATIO                                                      2010
YEAR                          REVENUE                                       RATIO                   WORKING
            EMPLOYEES                        (Current Assets/Current    (Total Liabilities/Total                BACKLOG
                                                                                                    CAPITAL
                                                   Liabilities)                 Equity)
 2010
 YTD                            $                                                                       $           $

 2009                           $                                                                       $               N/A

 2008                           $                                                                       $               N/A

 2007                           $                                                                       $               N/A


Trade References: Please provide contact information for three vendors with whom the company does business.



                                                    A-2
Attachment A
         a.) Vendor:                         Contact Name:
             Telephone:                      Fax:

         b.) Vendor:                         Contact Name:
             Telephone:                      Fax:

         c.) Vendor:                         Contact Name:
             Telephone:                      Fax:


Project References: Please provide contact information for six projects performed within the past year.
         a.) Largest Project Ever
             Project Name:                 General Contractor:
             Contract Amount:              Project Completion Date:
             Contact Name:                 Telephone:                          Fax:

         b.) Largest Project This Year
             Project Name:                   General Contractor:
             Contract Amount:                Project Completion Date:
             Contact Name:                   Telephone:                          Fax:

         c.) Largest Project Last Year
             Project Name:                   General Contractor:
             Contract Amount:                Project Completion Date:
             Contact Name:                   Telephone:                          Fax:


Preferred Project Size: Please indicate the company’s top five preferred project size categories using a scale of 1-5,
with 1 being most preferred.

               Under $50K                $3M - $6M
               $50K - $100K              $6M - $10M
               $100K - $200K             $10M - $15M
               $200K - $500K             $15 - $25M
               $500K - $1M               $25M - $50M
               $1M - $3M                 Over $50M


Insurance Information
Insurance Company:
Address:                                     City, State, and Zip:
Local Agent:                                 Telephone:            Fax:


Bonding Information
Bonding Company:
Address:                                     City, State, and Zip:
Local Agent:                                 Telephone:            Fax:




                                                    A-3
Attachment A

AM Best Rating:
Total Bonding Capacity: $                   Current Available Bonding Capacity: $

11. Select the Industry or Industries that the company routinely performs work in.

           Ethanol
           Food/Food Processing
           Manufacturing                 Type(s):
           Power – Industrial
           Power – Solar
           Power – Wind
           Power - Other                 Type(s):
           Refinery                      Type(s):
           Water
           Waste Water
           Other Industry Not Listed
           Other Industry Not Listed
           Other Industry Not Listed
           Other Industry Not Listed
           Other Industry Not Listed


12. Select the Scope of Work Sections that the company performs.

     1000       CONSULTANTS                               2000     SITE CONSTRUCTION (CONTINUED)
       1000     Construction Estimating Consultants         2955   Lawn Maintenance Services
       1100     Geotech/Enviro/NDE/NDT Consultants          2970   Fountains
       1200     Landscaping Consultants                            Other
       1300     Architectural Consultants
       1400     Engineering/Structural Consultants        3000     CONCRETE
                Other                                       3000   Building Concrete Sub’s
                                                            3030   Tilt-Up Concrete Sub’s
     2000       SITE CONSTRUCTION                           3050   Site Concrete Sub’s
       2000     Site Demolition Work                        3070   Redi-mix Concrete Suppliers
       2020     Concrete Saw-cut/Core Drilling              3080   Concrete Accessories
       2030     Hazard. Matl Remediation/Abatement          3090   Concrete Lifting
       2070     Erosion/Sedimentation Control               3100   Concrete Formwork
       2080     Lime Stabilization Subs                     3150   Concrete Pumping Services
       2100     Dewatering                                  3200   Concrete Reinforcement
       2120     Tree Trimming/Cutting/Removal               3350   Shotcrete
       2200     Earthwork & Excavating Subs                 3370   Gunite & Epoxy Ejection
       2220     Rock Removal/Drilling/Blasting              3380   Post-Tensioned Concrete
       2270     Soil Termite Treatment                      3400   Structural Precast Concrete
       2300     Piles & Caissons                            3425   Architectural Precast Concrete
       2330     Gabions                                     3430   Precast Thin Brick/Conc Panels
       2350     Shoring & Underpinning                      3450   Precast Parking Structures
       2470     Asphalt Paving & Striping                   3475   Precast Plans
       2500     Water Wells & Well Drilling                 3490   Precast Erection
       2550     Fuel & Steam Distribution                   3500   Cementitious Decks & Toppings
       2660     Site Utility Work Sub’s                     3550   Decorative Concrete Finishes
       2650     Site Utility Equip/Matl Suppliers           3570   Floor Hardeners & Sealing
       2660     Ponds & Reservoirs                          3900   Concrete Restoration/Cleaning




                                                    A-4
Attachment A
      2810     Walk/Rd/Parking Appurtenances                     Other
      2830     Fences & Gates
      2850     Unit Pavers/Retaining Walls              4000     MASONRY
      2900     Landscaping & Seeding                      4000   Masonry Sub’s
      2950     Lawn Irrigation Systems                    4020   Masonry Material Suppliers
    4000       MASONRY (CONTINUED)                      7000     THERMAL AND MOIST. PROT. (CONT’D)
      4050     Masonry Accessories                        7200   Building Insulation/Vapor Retarder
      4150     Masonry Insulation Systems                 7210   Pre-Eng. Building Insulation
      4180     Masonry Reinforcing                        7220   Foamed-in-place Insulation
      4220     Concrete Unit Masonry Supplier             7250   E.I.F.S.
      4270     Glass Masonry Units                        7280   Sprayed-On Fireproofing
      4400     Stone & Granite Matl Suppliers             7300   Shingles & Roof Tiles
      4500     Refractory – Fire Brick                    7400   Manufact. Roofing/Siding Panels
      4700     Simulated Masonry                          7430   Siding & Soffit Systems
      4800     Masonry Assemblies                         7500   Membrane & Built-Up Roofing
      4890     Masonry Waterproofing/Sealing              7550   Traffic Coatings
      4900     Masonry Restoration and Cleaning           7600   Flashing, Sheet Metal
               Other                                      7700   Roof Specialties & Accessories
                                                          7740   Roof Hatches & Smoke Vents
    5000       METALS                                     7750   Roof Pavers & Roof Walkways
      5000     Structural Steel & Aluminum                7810   Fire stopping
      5050     Metal Fasteners & Accessories              7900   Joint Sealers & Caulking
      5080     Metal Coatings                                    Other
      5100     Steel Erection Sub’s
      5200     Metal Joists                             8000     DOORS AND WINDOWS
      5300     Metal Decking                              8100   Metal Doors & Frames Suppliers
      5400     Cold – Formed Metal Framing                8200   Wood & Plastic Door Suppliers
      5500     Misc. Metals Fabrications                  8250   Doors/Hardware Installation Subs
      5510     Metal Stairs & Ladders                     8300   Specialty Doors
      5520     Handrails & Railings                       8340   Sectional Overhead Doors
      5525     Column Covers                              8400   Entrances & Store fronts
      5530     Gratings & Floor Plates                    8450   Automatic Entrance Door
      5540     Mezzanines                                 8500   Metal Windows
      5600     Sheet Metal Fabrications                   8570   Security Windows & Screens
      5700     Ornamental Metals                          8600   Skylights
      5800     Expansion Joints Assemblies                8700   Door & Window Hardware
      5900     Metal Restoration & Cleaning               8800   Glass, Glazing & Mirrors
               Other                                      8900   Glazed Curtain Walls
                                                                 Other
    6000       WOOD AND PLASTICS
      6000     Lumber Material Suppliers                9000     FINISHES
      6050     Fasteners/Adhesives & Hardware             9100   Non-Load Bearing Wall Framing
      6100     Rough Carpentry Sub’s                      9200   Lath & Plaster
      6120     Finish Carpentry Sub’s                     9250   Gypsum Board
      6130     Heavy Timber Construction Sub’s            9300   Tile
      6150     Pole Buildings                             9400   Terrazzo
      6170     Wood Trusses                               9450   Stone Facing
      6175     Wood Hybrid Roof Framing Systems           9500   Acoustical Ceilings
      6180     Glue-Laminated Construction                9520   Metal Ceiling Systems
      6200     Architectural Woodwork/Millwork            9570   Wood Flooring
      6300     Wood Stairs                                9600   Stone Flooring
      6400     Manufactured Columns/Moldings              9630   Unit Masonry Flooring
      6600     Plastic Fabricators                        9640   Fluid Applied Flooring
      6650     Solid Surface/Cultured Marble              9650   Resilient Flooring
      6600     Wood & Plastic Rest. & Cleaning            9670   Carpet




                                                  A-5
Attachment A
               Other                                       9675    Flooring Material Suppliers
                                                           9800    Epoxy & Special Floor Coatings
    7000       THERMAL AND MOIST. PROTECTION               9830    Acoustical Treatment/Sound Panels
      7100     Waterproofing                               9900    Painting Sub’s
      7150     Damp proofing                               9970    Wall Coverings
      7190     Water Repellents                                    Other
    10000      SPECIALTIES                               13000     SPECIAL CONSTRUCTION
      10100    Visual Display Boards                       13030   Special Purpose Rooms
      10120    Toilet Partition/Urinal Screen              13040   Cold Storage Rooms/Facilities
      10150    Cubicle Curtains & Track                    13080   Sound/Vibration/Seismic Control
      10200    Louvers & Vents                             13100   Lighting Protection
      10240    Grilles & Screens                           13120   Pre-Engineered Structures
      10260    Wall and Corner Guards                      13125   Pre-Engineered Metal Building Systems
      10270    Access Flooring                             13127   Pre-Engineered Metal Building Erectors
      10290    Pest & Animal Control Devices               13150   Swimming Pools/Hot Tubs/Saunas
      10340    Manufactured Exterior Specialties           13170   Heliports
      10350    Flagpoles                                   13200   Liquid & Gas Storage Tanks
      10400    Exterior Signage                            13700   Security Access and Surveillance
      10420    Interior Signage                            13800   Building Automation & Control
      10500    Lockers                                     13850   Detection & Alarm
      10520    Fire Extinguishers and Cabinets             13900   Fire Suppression
      10530    Awnings/Protected Walk Covers                       Other
      10550    Postal Specialties
      10600    Wire Mesh Partitions                      14000     CONVEYING SYSTEMS
      10620    Demountable Partitions                      14200   Elevators
      10650    Operable Partitions                         14300   Escalators & Moving Walks
      10670    Storage Shelving                            14500   Material Handling System/Conveyors
      10750    Telephone Specialties                       14580   Pneumatic Tube System
      10800    Toilet & Bath Accessories                   14600   Overhead Hoists & Cranes
      10950    Miscellaneous Specialties                   14950   Miscellaneous Conveying Systems
               Other                                               Other

    11000      EQUIPMENT                                 15000     MECHANICAL
      11015    Vacuum Cleaning Systems                     15300   Fire Protection Sub’s
      11050    Library Equipment                           15400   Plumbing Sub’s
      11060    Theatre and Stage Equipment                 15470   Refrigeration Sub’s
      11120    Vending Equipment                           15480   Medical Gas Equipment & Piping
      11130    Audio-Visual Proj. Screen Equipment         15500   HVAC Sub’s
      11140    Vehicle Service Equipment                   15700   HVAC Matl/Equipment Suppliers
      11150    Parking Control Equipment                   15725   Radiant Heating Systems
      11160    Loading Dock Equipment                      15900   HVAC Instrumentation & Controls
      11170    Solid Waste Handling Equipment                      Other
      11190    Detention Equipment
      11200    Water Supply & Treatment Equipment        16000     ELECTRICAL
      11280    Hydraulic Gates & Valves                    16000   Electrical Sub’s
      11300    Fluid Waste Treat/Disposal Equipment        16300   Electrical Service/Power Distribution
      11460    Unit Kitchens                               16400   Substations
      11490    Specialty Equipment                         16500   High Voltage Transmission Lines
      11500    Industrial and Process Equipment            16500   Lighting Suppliers
      11600    Laboratory Equipment                        16550   Medical/Surgical Lighting
      11700    Medical Equipment                           16700   Sound & Communication Sub’s
      11900    Exhibit Equipment                           16800   Security/Surveillance Systems
               Other                                       16900   Fire Alarm Systems
                                                                   Other
    12000      FURNISHINGS




                                                   A-6
Attachment A
         12300     Manufactured Casework                        OTHER SCOPES OF WORK NOT LISTED
         12400     Window Treatments & Blinds
         12950     Miscellaneous Furnishings
                   Other




13. Select the states that the company is licensed to perform work in.

             Alabama            Hawaii          Massachusetts              New Mexico       South Dakota
             Alaska             Idaho           Michigan                   New York         Tennessee
             Arizona            Illinois        Minnesota                  North Carolina   Texas
             Arkansas           Indiana         Mississippi                North Dakota     Utah
             California         Iowa            Missouri                   Ohio             Vermont
             Colorado           Kansas          Montana                    Oklahoma         Virginia
             Connecticut        Kentucky        Nebraska                   Oregon           Washington
             Delaware           Louisiana       Nevada                     Pennsylvania     West Virginia
             Florida            Maine           New Hampshire              Rhode Island     Wisconsin
             Georgia            Maryland        New Jersey                 South Carolina   Wyoming



Please include with the completed survey, electronic copies of the following items:
         1. A certificate of insurance evidencing adequate coverage is in place (see page A-8 for minimum liability
             requirements).
         2. Financial statements for the past three years, including latest balance sheet and income statement.
         3. Completed Bank Authorization Release of Information form (page A-9).
         4. Completed W-9 form (page A-10).


Additional Remarks:




COMPLETED BY:

Signature:                                                      Printed:

Title:                                                          Date:




                                                   A-7
Attachment A




                               MINIMUM LIMITS OF LIABILITY FOR ALL CONTRACTORS

General Liability/Occurrence Policy:
Commercial General Liability               General Aggregate                  $2,000,000
Premises & Operations                      Occurrence                         $1,000,000
Products & Completed Operations            Aggregate                          $2,000,000
Personal & Advertising Injury              Aggregate                          $1,000,000
Fire Damage                                Any One Fire                       $ 50,000
Medical Payments                           Single Limit                       $    5,000

Automobile Liability:
Any One Auto                               Combined Single Limit
Hired Autos                                Bodily Injury/Property Damage
Non-Owned                                  Per Accident                       $1,000,000

Worker’s Compensation:
Worker’s Compensation Policy must cover every state in which the company does business with Bowen
Engineering Corporation.
Each Accident                                                               $ 500,000
Disease Per Policy                                                          $ 500,000
Disease Per Employee                                                        $ 500,000

Commercial Umbrella:
Limit of Liability Each Occurrence                                            $2,000,000
Limit of Liability Annual Aggregate                                           $2,000,000


If the Contractor’s Work involves or includes handling, transporting, disposing or performing operations with
hazardous substances, contaminants, waste, toxic materials or any other pollutants, including lead abatement,
Contractor shall provide the following Pollution Liability Insurance.

Pollution Liability:                       Occurrence/Aggregate               $1,000,000




                                                  A-8
Attachment A




                             BANK AUTHORIZATION RELEASE OF INFORMATION FORM




         Bank Name:

         Address:

         City, State, Zip:

         Telephone:

         Fax No:

         Contact:



Dear Sir or Madam:

The below signature of an authorized company representative serves as authorization for release of financial
information for purpose of a credit inquiry from Bowen Engineering Corporation.


Signature:

Printed Name:

Title:

Company Name:




                                                  A-9
Attachment A




               A-10
Attachment B




                             Contractor Safety Pre-qualification Survey


Company’s Legal Name:

Street Address:

City, State, and Zip:

Safety Director:                           Telephone:               Fax:

E-Mail Address:

Additional Safety Contact:                 Telephone:               Fax:

Email Address:                             Title:


In the chart below, please record your company’s safety performance numbers for the past three years and current
year-to-date.

                                                    LOST
                                                    WORK                                               # OF
 YEAR       MAN HOURS         RECORDABLES           DAYS     EMR      DART        RIR      LTIR     FATALITIES
  2010
  YTD

   2009

   2008

   2007

Please provide the company’s trade related SIC/NAICS Code:




                                                    B-1
Attachment B



Please answer the following questions regarding the Safety Program at your company.

                                                                                                 YES   NO   N/A
     1.   Does the company have a formal Safety Policy?
          a. Is it part of the Safety Manual?
          b. Does it include a Drug & Alcohol policy?
          c. Is it signed by the President or highest authority of the company?

     2.   Are there clearly defined safety responsibilities for management personnel?
          a. Are management safety responsibilities in writing?

     3.   Are there clearly defined safety responsibilities for employees?
          a. Are employee safety responsibilities in writing?
          b. Is there a method or methods in place for employees to communicate safety
              hazards?

     4.   Does the company designate an on-site safety representative for each jobsite?
          a. Does the company provide a MSDS for all hazardous material brought on site?

     5.   Does the company have a designated Safety Director?
          a. Does the Safety Director report directly to Management?
          b. Does the company have a written policy stating the role, authority and
             responsibility of the Safety Director?
          c. Has the Safety Director completed the OSHA 30-hour?

     6.   Is a new hire orientation conducted for new employees prior to conducting work?
          a. Do the topics include, at a minimum: emergency procedures, MSDS training, PPE
               requirements, Blood borne Pathogens awareness, basic electrical, lead and
               asbestos and general safety awareness?
          b. Is a record of new hire orientation attendance documented and maintained?

     7.   Does the company have a well defined Disciplinary Policy and Procedure?
          a. Do violations of the safety policies result in disciplinary action?
          b. Is all disciplinary activity noted in the employee personnel file?
          c. Is the disciplinary policy part of the new hire orientation?

     8.   Is a jobsite toolbox safety meeting conducted with all employees on a weekly basis?
          a. Is attendance at the weekly safety meeting documented and maintained?
          b. Is the topic of weekly safety meetings recorded and maintained?

     9.   Do all project managers, job superintendents and foremen receive ongoing training on
          the company’s safety policy?




                                                  B-2
Attachment B

                                                                                               YES   NO   N/A

    10. Does the company have a formal written HazCom program?
        a. Is the written HazCom policy posted on all jobsites?
        b. Is a specific person designated for the training and administration of the HazCom
           program?
        c. Are MSDS maintained for each hazardous chemical that is used?
        d. Is the location of MSDS documented?
        e. Are all secondary containers clearly labeled?
        f. Do all employees receive HazCom program training?

    11. Are job hazard analyses conducted and documented on a set schedule?
        a. Are corrective action or preventative action plans reviewed by management?

    12. Is there a designated person who conducts job site safety inspections?
        a. Does this person conduct random searches on a regular basis?
        b. Are safety inspections completed using a specific inspection form included in the
             safety program?
        c. Is corrective action documented in writing?

    13. Is a job-specific emergency action plan and procedure documented prior to the start
        of a job?
        a. Is the job-specific emergency action plan in writing?
        b. Are personnel responsibilities discussed at the start of a new job?
        c. Is necessary emergency equipment present on the jobsite prior to the start of a
              new job?

    14. Does the company have a written Accident Investigation and Reporting Policy?
        a. Are procedures for personal injury, property damage, chemical spill and other
           emergency situations clearly defined?
        b. Are all incidents reported using a company specific form?
        c. Are incident forms forwarded to management for accident analysis and review?
        d. Are injured employee and witness statements a routine part of the process?
        e. Are reporting procedures designed to find the incident cause and document and
           track prompt corrective measures?
        f. Are all personnel trained on accident investigation and reporting procedures
           during new hire orientation?

    15. Is an early return-to-work (light duty) program in place?
    16. Are job site personnel required to wear and maintain personal protective equipment?
        a. Is training on the proper use of PPE provided to employees?
        b. What PPE does the company provide to employees?
        c. What PPE are employees required to provide on their own?




                                                  B-3
Attachment B


The following sections of the survey are Trade Specific. Please answer only the section or sections that apply to your
company. Select N/A for all non-applicable sections.

                                                                                                    YES     NO     N/A
 Asbestos Handling & Removal Policy
     1. Are industry standards for housekeeping met?
     2. Are industry standards for Hygiene facilities and practices met?
     3. Are industry standards for competent person obligations met?
     4. Are industry standards for recordkeeping met?
     5. Does the company provide necessary protective clothing?
     6. Does the company provide respiratory protection including, selection, fit testing and
         medical evaluation?
     7. Are appropriate measures taken to monitor employee exposure levels?
     8. Are appropriate measures taken to notify other employers on-site of regulated areas?
     9. Are engineering controls and work practices properly explained?
     10. Are appropriate measures taken to establish regulated areas?

 Compressed Cylinder Handling/Storage Policy
    1. Are general safe handling and transporting policies adequately referenced?
    2. Are appropriate measures taken for compressed cylinder storage?
    3. Are appropriate measures taken for the separation of fuel gas cylinders from oxygen
        in storage?

 Electrical Safety Policy
     1. Does the company safety policy cover general electrical safety rules?
     2. Does the company safety policy explain general requirements regarding the use of
          temporary wiring and GFCIs?
     3. Does the company safety policy state the use of proper Personal Protective
          Equipment (PPE)?

 Fall Protection Plan
      1. Does the company have a written fall protection plan?
      2. Does the fall protection plan include requirements for fall protection on
          walking/working surfaces greater than 6 feet?
      3. Are all fall protection equipment and materials adequately inspected on a regular
          basis?
      4. Are all exposed employees trained on fall protection provisions, including a written
          certification?

 Hand/Power Tool Safety Policy
    1. Are all tools double insulated or properly grounded?
    2. Does the safety policy include provisions for identification and removal from service of
        any defective tool?
    3. Are guarding requirements clearly stated?




                                                   B-4
Attachment B

Hearing Conservation Policy                                                                      YES   NO   N/A
    1. Does the company have an annual training program for all employees exposed to
        noise at or above an 8 hour time weighted average of 85 dBA?
    2. Does the safety policy include provisions for required recordkeeping?
    3. Is a baseline audiogram provided within 6 months (12 months for mobile van) of
        employee exposure?
    4. Is audiometric testing performed by a licensed or certified audiologist,
        otolaryngologist or physician?
    5. Are all hearing conservation test results made available to affected employees?
    6. Is a system in place for employee notification of sound levels above the action level?

    7.   Does the company have a person designated to administer the hearing conservation
         program?
         If so, please provide the contact name:

Housekeeping Policy
   1. Does the company have documented general guidelines for keeping a clean jobsite?


Ladder Safety Policy
    1. Are exposed employees property trained on ladder safety?
    2. Does the ladder safety policy document common work rules regarding the proper
        type, use and limitations of ladders?

Manlift, Scissor Lift and Forklift Safety Policies
   1. Are appropriate measures taken to inspect equipment (daily if powered industrial
         truck)?
   2. Does the policy include how to document equipment inspections?
   3. Are employees trained in equipment operation prior to use?
   4. Are employees who operate powered industrial trucks (i.e. Forklift, rough terrain
         forklift, etc) appropriately certified prior to use?

Trenching/Excavation Safety Policy
    1. Does the safety policy cover adequate barrier protection for remotely located
        excavations?
    2. Does the safety policy cover proper installation/removal of shoring system supports (if
        applicable)?
    3. Does the safety policy cover requirements for protective systems (ex. Sloping,
        benching, shielding, shoring)?
    4. Does the safety policy cover determination of soil type by visual/manual testing?
    5. Does the safety policy cover fall protection on a trenching/excavation site?
    6. Does the safety policy cover stability of adjacent structures?
    7. Does the safety policy cover protection from hazards associated with water
        accumulation?
    8. Are measures in place for a competent person inspection every day prior to start of
        work, after a rainstorm or other hazard increasing occurrence?
    9. Does the safety policy cover procedures for identification of possible hazardous
        atmospheres?




                                                 B-5
Attachment B
                                                                                                   YES    NO     N/A

         10. Does the safety policy cover procedures for proper access and egress?
         11. Does the safety policy cover procedures for safe handling of underground utilities?

 Scaffolding Safety
     1. Are measures in place to ensure oversight of scaffold use by a competent person?
     2. Does the safety policy cover falling object protection?
     3. Does the safety policy cover safe use of scaffolding?
     4. Does the safety policy cover safe access of scaffolding?
     5. Does the safety policy provide criteria for supported scaffolds and/or suspension
          scaffolds?
     6. Does the safety policy cover procedures for scaffold platform construction?
     7. Does the safety policy cover policies on safe capacity for scaffolds?

 Crane/Rigging Safety
     1. Prior to use, is appropriate training provided to persons responsible for use and
         maintenance of cranes and rigging?
     2. Does the safety policy cover fire protection equipment requirements?
     3. Are all slings, chains, rope, etc inspected prior to and during use?
     4. Is all other crane/rigging equipment inspected prior to and during use?
     5. Does the safety policy cover measures to avoid electrical contact?
     6. Do employees use appropriate hand signals while using crane/ rigging equipment?
     7. Are appropriate procedures in place for required annual inspections of the hoisting
         machinery by a competent person recognized by the Department of Labor?

 Language of Policies
     1. Is all signage written in language(s) understood by all employees?
     2. Are all policies translated into the language of the workforce?


Please include with the completed survey, electronic copies of the following items:
         5. OSHA 300 and 300A logs for the current year-to-date and the past 3 calendar years.
         6. EMR verification letter for the current year-to-date and the past three years from your company’s
             insurance provider. If EMR verification is not applicable, please provide a letter stating such from your
             company’s insurance provider.
         7. Company safety policy.

Additional Remarks:




COMPLETED BY:

Signature:                                                       Printed:

Title:                                                           Date:




                                                      B-6
Attachment C




                            Contractor Quality Pre-qualification Survey

Company’s Legal Name:

Street Address:

City, State, and Zip:

Quality Control Manager:                      Telephone:            Fax:

E-Mail Address:


1.   Does the company have a full time Quality Manager?         Yes         No        Part time?          Yes   No
        a. If yes, please list. Name:              Title:

2.   Does the company have a written Quality program?         Yes           No

3.   Is the company LEEDS Certified?       Yes       No

4.   Does the company have experience with LEEDS projects?            Yes        No

5.   Does the company have a Quality orientation program for new hires?           Yes           No

6.   Does the company hold jobsite quality meetings for field supervisors?    Yes               No
             a. If yes, how often?    Weekly         Bi-weekly        Monthly                Less often

7.   Does the company conduct and document weekly site quality meetings?               Yes           No

8.   Does the company conduct and document weekly site quality inspections?              Yes              No

9.   By title, who will be responsible for supervising quality while on our work site?

10. Have the company’s site quality supervisors received formal quality training?             Yes         No
            a. If yes, please list.

11. Does the company have a program of progressive discipline for those who violate quality rules?              Yes   No

12. What is the company’s Quality Personnel to Craftsperson ratio?




                                                     C-1
Attachment C

13. What is the company’s Journeyman to Trainee/Apprentice ratio?

14. Does the company have a Certified Training/Apprentice program?       Yes       No
            a. If so, what is the name of your Certified Training program?

15. Does the company have an Inspection & Test Plan (ITP) program?       Yes      No

16. Has the company paid for any quality defects and/or rework during the last three years?    Yes      No
        If yes, explain:

17. Does the company have a program that tracks rework?       Yes       No

18. What is the company’s Cost of Rework Rate?
       Cost of Rework Rate (CRR) = Total Direct Cost of Rework/Actual Construction Cost

19. Please list all certifications held by the company.

Please include with the completed survey an electronic copy of the company’s Quality Control Program.

Additional Remarks:




COMPLETED BY:

Signature:                                                  Printed:

Title:                                                      Date:




                                                     C-2

								
To top