CS-01 Contractor Pre-qualification Information
We have anhydrous ammonia and manage the hazards of ammonia through implementation of a Process Safety Management (PSM) and Risk Management Program (RMP) per OSHA and EPA requirements. Under these programs we have established a screening process so that we hire and use contractors who accomplish the desired job tasks without compromising the safety and health of employees at a facility. We must obtain and evaluate information regarding your safety performance and programs. NOTE: >>This process APPLIES to any contractors working in or around PSM or RMP regulated process areas (e.g., inspection/renovation/repair of all refrigeration and other area equipment) that can reasonably be supposed to affect the process. All work in the vicinity of a regulated process is included (e.g., electrical, roofing work near ammonia piping, rack construction in conditioned spaces). It can be applied to all other contractors or hazardous chemical/construction contract work at the plant’s discretion. >>This process DOES NOT APPLY to incidental services - those which have little potential for contractors causing adverse events (e.g., janitorial work, laundry, vending services, landscaping, deliveries, design, and non-construction site consulting or no-contact visual inspection). These “incidental” contractors, subcontractors and service providers will receive instructions on facility alarms and evacuation or be escorted while onsite. >>To facilitate our review, please provide the following:
Which company or facility requested this prequalification form?
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Company Name
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Company Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years in business under present firm name
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Safety Contact
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First Name
Last Name
Safety Contact Email
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example@example.com
24 Hour Phone
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Format: (000) 000-0000.
Location and Description of Work for this Facility:
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Insurance
Do you have insurance meeting site requirements?
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Yes
No
If No, Explain:
Attach Certificate (COI)
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References
Major Jobs Completed in Last 3 Years:
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Rows
Customer
Project
Contact
1)
2)
3)
Safety Performance Information
Has the company received OSHA citations or safety/health related judgments, claims, contract terminations or pending/outstanding lawsuits (including by your or customer employees) against your Company in the last 5 years?
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Yes
No
If Yes, attach OSHA citations and explanation of any other items.
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Workers Comp Experience Modification Rate (EMR)
Obtain your EMR rate information from your insurance agency. All insurance agencies are required to provide the EMR rate to their corporate customers at the beginning of each fiscal year. If you are unsure about your current EMR rate, contact your insurance agent to find out what your rate is. Your EMR rate can also be found on the “Declarations” page of your company’s workers’ compensation policy. If you have been in business for less than 3 years or if you are a smaller company, you will not have an EMR and should put 1.0.
Experience Modification Rating (EMR)
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Rows
This Year
Last Year
Year Before
Experience Modification Rate (EMR)
Summarize the data shown on your OSHA Form 300 for all injuries year-to-date and the last 2 years:
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Rows
This Year
Last Year
Year Before
Recordable
Restricted Duty
Lost time
# of Days Lost
List injury incidence rates for year to date and for the last 2 years :
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Rows
This Year
Last Year
Year Before
Incdence Rate = (Total number of injuries and illnesses/ Employee hours worked) X 200,000
Recordable Rate = (OSHA recordable injuries and illnesses/ Employee hours worked) X 200,000
Lost Time Rate = (Lost Time injuries and illnesses/ Employee hours worked) X 200,000
Severity (SR) = (No of work days lost + light duty days lost/ Employee hours worked) X 200,000
Safety Programs Information
Do you have written Safety and Health Programs?
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Yes
No
Please upload a list of written programs or a Table of Contents
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Do you have a training program to support the above Programs?
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Yes
No
Attach list of training provided to employees who will work at the facility.
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Do you hold safety meetings?
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Yes
No
How often are your safety meetings held?
e.g. Daily, Weekly, Monthly, etc.
Are your safety meetings documented?
Yes
No
Do you have experience working on or around process systems that contain ammonia or any other material listed in 29 CFR §1910.119, Appendix A and 40 CFR § 68.130?
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Yes
No
Certification
I certify that the Health and Safety and Training Programs for our company comply with OSHA and other applicable regulatory requirements and that the information presented on this form and attachments is accurate and complete. Our company is aware of and understands its obligations under OSHA, EPA and other applicable standards and will abide by applicable facility Contractor Safety, Health & Environmental procedures, as appropriate. Our company will advise the facility prior to beginning work, of any hazardous substances it or any of its sub-contractors will bring on premises and/or any safety issues that could be created by its work. Such information, including SDS for hazardous substances, will be communicated in writing to the Facility Representative. Likewise, if the Contractor’s work will pose any safety issues for the Facility’s employees, the issues will be discussed with the Facility Representative before commencing that portion of the work.
Name
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First Name
Last Name
E-mail
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Phone
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Format: (000) 000-0000.
Signature
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Submit
Submit
Should be Empty: