Pre-Qualification

*** Notice ***
Please use this information sheet as a reference of info provided in this form.

Summary of Required Documentation

Step 1 of 5

Safety Questionnaire
Primary NAICS Code(s):
Project Name/Location/Dates (if available):
Experience Modification Rates: Experience modification rates (EMR) are established by your insurance carrier based on past claims for losses including worker’s compensation. Please contact your insurance carrier to obtain verification of your EMR for each year requested. If an EMR has not been established for your company for each year requested, please attach an explanation.

If any EMR rate listed is greater than 1.0, you must attach a corrective action plan. The corrective action plan must explain why the EMR(s) are greater than 1.0, and descriptions of the corrective action(s) that have been implemented to reduce the EMR to 1.0 or less.

Incidence Rate Calculations: The Incidence Rates that you insert into the table (from your OSHA 300 Logs) will be compared to the U.S. Bureau of Labor Statistics tabulated Incidence Rates for the most recent year available. The Incidence Rates used will be that of the North American Industry Classification System (NAICS) code which most closely represents the nature of the work to be performed by your firm on the subject project.

If any Incidence Rate listed is greater than the appropriate National Average, you must attach a Corrective Action Plan. The Corrective Action Plan must explain in detail why the Incidence Rates are above the National Averages, as well as descriptions of the corrective action(s) that have been implemented to reduce the Incidence Rates, and a demonstration of the effectiveness of the corrective actions to date.

Fatalities: If any fatalities are indicated, a detailed explanation of the fatality must be provided. In addition, you must attach a Corrective Action Plan. The Corrective Action Plan must contain detailed descriptions of the corrective action(s) that have been implemented to prevent recurrence of similar incidents in the future, and a demonstration of the effectiveness of the corrective actions to date
Experience Modification Rate*
Current Year Previous Year Previous Year Previous Year
Total Employee Hours Worked by Calendar Year*
(both office and field labor)
Current Year Previous Year Previous Year Previous Year
Total Recordable Injuries and Illnesses*
(OSHA 300 Form – Columns G+H+I+J)
Current Year Previous Year Previous Year Previous Year
Total Recordable Incidence Rate*
(Row 3 / Row 2) x 200,000 work hours
Current Year Previous Year Previous Year Previous Year
Number of Cases that Involved Days Away From Work, Days of Restricted Work Activity, or Job Transfer (DART)*
(OSHA 300 Form – Columns H + I)
Current Year Previous Year Previous Year Previous Year
DART Incidence Rate*
(Row 5 / Row 2) x 200,000
Current Year Previous Year Previous Year Previous Year
Number of Cases that Involved Days Away From Work (Lost Time Cases)*
(OSHA 300 Form – Column H)
Current Year Previous Year Previous Year Previous Year
Lost Time Incidence Rate*
(Row 7 / Row 2) x 200,000
Current Year Previous Year Previous Year Previous Year
Total Number of Fatalities*
Current Year Previous Year Previous Year Previous Year
Substance Abuse Programs
Does your company have a substance abuse program which includes pre-work (or pre-employment), “for cause”, and post accident employee drug and alcohol testing?*
Will you implement substance abuse testing for work subcontracted to your company?*
Does your company have a program in place that complies with the Federal Drug-Free Workplace Act?*
Will you implement a Drug-Free Workplace Program that complies with federal requirements (FAR Clause 52.223-6) for work subcontracted to your company?*

Other Compliance History
The following compliance questions relate to your company and operations over the past 5-year period. The term company is inclusive of all operations nationwide, all companies and operating divisions, and all company names currently and previously used.
Has OSHA (federal or state) issued any citation(s) to your company?*
Has OSHA (federal or state) issued any citation(s) to subcontractors working on projects or sites managed by your company?*
Are there any past or pending environmental enforcement actions or environmental compliance violations for your company?*
For projects, subcontractors, or sites managed or operated by your company, are there any past or pending environmental enforcement actions or environmental compliance violations for any other related organization? (Note: Related organizations would include subcontractors, site owners, other companies or government organizations. This question is limited to the time period when your company was in management or operational control of the project or site.)*
Be Prepared to send a copy of the violation, citation, or enforcement action description, including an explanation of the circumstances and resolution(s) with the agency. Please provide a discussion of what corrective action(s) have been implemented to prevent recurrence at other locations, and demonstrate how these actions have been effective

Confirmation
I certify and declare under penalty of law that the foregoing environmental health and safety compliance history is true and correct, and that I am a duly authorized representative of the company.
Print Your Name*
Your Title*
Date*
MM slash DD slash YYYY
Please Sign With Your Mouse*
Company contact for additional health, safety and environmental program information
Name*
Title*
Phone*
Fax
Email

Step 1 of 5

Contact Information

Company Information

Safety Questionnaire

Substance Abuse Programs

Environmental Health

Other Compliance History

Confirmation

Company contact for additional health, safety and environmental program information

Current Year	Previous Year	Previous Year	Previous Year

Current Year	Previous Year	Previous Year	Previous Year

Current Year	Previous Year	Previous Year	Previous Year

Current Year	Previous Year	Previous Year	Previous Year