Contractor Safety Pre-Qualification Assessment

Contractor Safety Pre-Qualification Assessment
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1. Your Legal Business Name
2. Business Year of Establishment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3. Name of Company Safety Director

First NameLast Name
4. Safety Director Email
example@example.com
5. Safety Director Phone Number

Area CodePhone Number
6. Highest Ranking Safety/Health Professional in the Company
Notes

21. Safety & Health Programs Management?

Rows	Yes	No	Partially
a. Do you have or provide a full-time Safety Director?
b. Do you have or provide a full-time field environmental representative?
c. Do you have or provide a full-time field safety coordinator?
d. Do you have or provide a safety incentive program?
e. Do you have or provide company paid safety training?

22. Safety & Health Programs & Procedures?

Rows	Yes	No	Partially
a. Management commitment and expectations?
b. Employee participation?
c. Accountabilities/responsibilities for managers, supervisors, and employees?
d. Resources for meeting safety & health requirements?
e. Periodic safety & health performance appraisals for all employees?
f. Do you have a safety recognition program?
g. Do you have a Hazard Recognition and Control Program?

23. Does the program include work practices and procedures such as:

Rows	Yes	No	Partially	N/A
a. Energy Control Lockout/Tagout (LO/TO)
b. Hot Work
c. Confined Space Entry
d. Accident/Incident Reporting & Investigation
e. Unsafe Condition Reporting
f. Occupational Injury & Illness Reporting
g. Bloodborne Pathogens
h. Fall Protection
i. Personal Protective Equipment
j. Portable Electrical/Power Tools
k. Electrical Safe Work Practices
l. Electrical Equipment Grounding Assurance
m. Vehicle Safety
n. Rigging and Heavy Equipment
o. Powered Industrial Vehicles (Cranes, Forklifts, JLGs, etc.)
p. Housekeeping
q. Emergency Preparedness and Response Procedures (Including Evacuation Plan)
r. Fire Protection
s. Waste Disposal
t. Environmental Spill or Leak Prevention
u. Back Injury Prevention
v. Scaffolding (User)
w. Excavation/Trenching & Shoring
x. Abrasive Blasting
y. Hydroblasting
z. Emergency Action Plan as per 29CFR 1910.38

24. Are there written programs for the following:

Rows	Yes	No	Partially	N/A
a. Hearing Protection/Hearing Conservation
b. Respiratory Protection, where applicable, have employees been:
Trained?
Fit Tested?
Medically approved?
Have employees been trained in Hazard Communication?
Company maintained SDS library for all chemicals?
Is appropriate respiratory equipment provided as appropriate?

25. Do you have a substance abuse program?

26. Do you conduct medical examinations for:

Rows	Yes	No	N/A
a. Pre-employment placement
b. Pre-placement Job capability
c. Hearing Function {Audiograms}

28. Do you hold Pulsar Helium site specific Safety & Health meetings for:

29. If applicable, is there a PPE Program that:

Rows	Yes	No	Partially	N/A
a. Makes PPE readily available to workers as applicable?
b. Does the PPE program assure that PPE is inspected and maintained?

Notes
30. Do you have a corrective action process for addressing individual safety and health performance deficiencies?
Notes

31. Do you have a written environmental management program that:

Rows	Yes	No	Partially	N/A
a. Includes employee awareness training?
b. Includes safety assessment procedures?
c. Include provisions for identifying physical impacts to the environment and how to control or mitigate those risks?

32. Equipment & Materials:

Rows	Yes	No	N/A
a. Does your company have a system or process for establishing applicable health, safety, and environment specifications for acquisition of materials and equipment?
b. Do you conduct inspections on company owned or operated equipment (e.g. cranes. forklifts, JLG, etc.) in compliance with regulatory requirements?
c. Do you maintain the applicable inspection and maintenance certification records for operating equipment?

33. Subcontractors:

Rows	Yes	No	N/A
a. Do you use subcontractors? (Identify subcontractors in the notes)
b. Do you use safety & health performance qualification criteria in the selection of subcontractors?
c. Do you evaluate the ability of subcontractors to comply with applicable health & safety requirements as part of the selection and contractor management process?
d. Do your subcontractors have a written Safety & Health Program and are the requirements of that program executed in practice?
e. Do you include your subcontractors in:
Safety & Health Orientations
Safety & Health Meetings
Audits/Inspections/Assessments

34. Does your company have a Short Service Employee (SSE) policy that:

Rows	Yes	No	N/A
a. Identifies new employees or experienced employees new to your company or new to their position?
b. If yes, does the SSE policy include a mentor being assigned to the SSE?
c. If yes, does it define the roles and responsibilities of the mentor?
d. Is the SSE program applied in practice?

35. Safety Training?

Rows	Yes	No	Partial	N/A
a. Have employees been trained in appropriate job skills?
b. Do you have a process to assess skills of your workers to assure they are qualified?
c. Are employees job skills certified where required by Regulatory or Industry consensus standards?
d. Are all employees trained in the work practices needed to safely perform his/her job?

36. Safety and Health Orientation?

Rows	Yes	No	N/A
a. Do you have a Safety and Health Orientation Program for new hires and newly hired or promoted supervisors?
b. Does the program provide instruction for the following:
New Worker Orientation
Safe Work Practices
Safety Supervisor
Toolbox Safety Meetings
Emergency Procedures
HazWoper/Emergency Response
First Aid Procedures
Incident Reporting and Investigation
Fire Protection and Prevention
Safety Intervention
Hazard Communication
Environmental Awareness