Contractor HSE Management Pre-Qualification
Contractor HSE Management Pre-Qualification
Telephone: Fax:
City: Country Postal Code:
Subsidiaries:
ORGANIZATION
8. Form of Business Sole Owner Partnership Corporation
9. Percentage Owned:
10. Describe Services Performed:
Construction Maintenance
Original Manufacturer and Installer Service Work (e.g. janitorial, clerical, etc.)
Project Management Workforce and Resources
Original Equipment Manufacturer and Construction Design
Other – describe below:
11. Describe Services Performed:
12. List other types of work within the services you normally perform that you subcontract to
others (including brokers):
14. Attach a list of major equipment (e.g. cranes , JLGs, forklifts) the company has available for
work and the method of establishing competency to operate.
16. Annual US$ dollar volume of the past three years 20____ 20___ 20___
$ $ $
22. Are there any judgements, claims or suits pending or outstanding against your company?
Yes No
If Yes, please attach details
23. Are you now or have you ever been involved in any bankruptcy or reorganization
proceedings? Yes No
If Yes, please attach details
25. List the past three years Injury Incidence Rate (including sub-contractors)
26.
32 Does the program include work practices and procedures such as:
a. Equipment lockout Yes No
b. Confined space entry Yes No
c. Injury & illness recording Yes No
d. Fall protection Yes No
e. Personal protective equipment Yes No
f. Portable electrical/power tools Yes No
g. Vehicle safety Yes No
h. Compressed gas cylinders Yes No
i. Electrical equipment grounding assurance Yes No
j. Powered industrial vehicles(cranes, forklifts, JLGs, etc.) Yes No
k. Housekeeping Yes No
l. Accident/incident reporting Yes No
m. Unsafe condition reporting Yes No
n. Emergency preparedness, including evacuation plan Yes No
o. Waste disposal Yes No
c. MSDS Yes No
35 Medical
a. Do you conduct medical examinations for:
Pre-employment Yes No
Replacement job capability Yes No
Pulmonary Yes No
Respiratory Yes No
b. Describe how first aid and medical services will be provided for employees while on-site.
Specify who will provide this service:________________________________________
c. Are there personnel trained to perform first aid and CPR? Yes No
38 Is there a corrective action process for addressing individual Health, Safety and
Environmental performance deficiencies Yes No
40 Subcontractors
a. Is Health, Safety and Environment, performance criteria used in Yes No
selection of subcontractors?
c. Is the ability of subcontractors to comply withapplicable Yes No
Health, Safety and Environment requirements evaluated as part
of the selection process?
c. Do your subcontractors have a written Health, Safety Yes No
and Environment Program?
d. Are subcontractors included in:
Health, Safety and Environment orientation Yes No
Health Safety and Environment meetings Yes No
Inspections Yes No
Audits Yes No
42 Craft Training
a. Are employees trained in appropriate job skills? Yes No
b. Are employees job skills certified where required by Yes No
regulatory or industry consensus standards?
d. List crafts which have been certified:
___________________________
___________________________
___________________________
___________________________
___________________________
45 Training Records
a. Are there Health, Safety and Environment Craft training records Yes No
for employees?
b. Do the training records include the following:
Employee identification Yes No
Date of training Yes No
Name of trainer Yes No
Method used to verify understanding Yes No
INFORMATION SUBMITTAL
Are copies of the following items with complete PQF provided:
Health, Safety and Environment program
Health, Safety and Environment incentive program
Substance Abuse program
MSDS program
Respiratory Protection program
Housekeeping policy
Accident/Incident investigation procedures
Health, Safety and Environment inspection form
Health, Safety and Environment audit procdure or form
Health, Safety and Environment training program (outline)
Example of employee Health & Safety and Environment training records
Health, Safety and Environment training schedule (sample)
Health, Safety and Environment training for supervisors (outline)
Qualification requirements for Health, Safety and Environment representatives
Contractor is:
Acceptable for approved contractors list Yes No
Conditionally acceptable for approved contractors list Yes No
Comments/Conditons: