Subcontractor Prequalification Questionnaire

Company Name:*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Name*

First NameLast Name

Primary Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Primary Contact Email*

example@example.com

Additional Contact Name

First NameLast Name

Additional Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Additional Contact Email

example@example.com

Have you previously worked for K&W Underground?*

YesNo

State(s) licensed to perform work?*

What area of fiber construction work do you specialize in?*

AerialFiber SplicingBoringOther

If boring is your specialty, are you able to bore in rock?*

YesNoN/A

Previous Work Experience / Types of Projects Completed in the Past: (Include details such as: boring through rock, cable sizes worked with)*

Types of Equipment and/or Trucks Owned:*

How did you hear about K&W Underground? (ie: Word of Mouth, Facebook, Indeed, Previously Worked for K&W)*

Are you available for emergency response?*

YesNo

Does your company have a written safety policy or program in place?*

YesNo

If yes, how often is your safety policy reviewed and updated? If no, simply type N/A.*

Copy of written safety policy or program, if applicable.

What safety training is provided to your employees?*

How often is safety training conducted?*

Are employees trained in first aid and CPR?*

YesNo

Are Toolbox Talks or Safety Meetings held regularly?*

YesNo

If yes, how often? If no, simply type N/A.*

Have employees been trained on Locate Laws?*

YesNo

If yes, what was the date of the last training? If no, simply type N/A.*

Do you have emergency response plans in place for your worksites?*

YesNo

How are employees trained on emergency procedures?*

What personal protective equipment (PPE) is required for your employees?*

How do you ensure the proper use and maintenance of PPE?*

What is your process for reporting and investigating incidents and accidents?*

How do you track and analyze incident data to identify trends and implement corrective actions?*

Are you in compliance with all relevant federal, state, and local safety regulations?*

YesNo

Have you had any safety-related violations, citations, or insurance recommendations in the past three years?*

YesNo

If yes, please provide details. If no, simply type N/A:*

Please provide any additional information about your company's safety practices that you believe is relevant to this project.

I, the undersigned, hereby certify that the information provided in this Subcontractor Safety Questionnaire is accurate and complete to the best of my knowledge. I understand that providing false or misleading information may result in disqualification from participating in any K&W Underground, Inc project. The subcontractor agrees to cooperate with safety practices, rules and regulations, standards and criteria set or instituted by K&W Underground, Inc, which agreement is in further of the subcontractor’s duties and responsibilities under the Occupational Safety and Health Act.

The Subcontractor agrees that if, in the opinion of K&W Underground, Inc the health and safety of a worker is endangered or the operation at a job site is not implementing appropriate safety precautions, K&W Underground, Inc may take actions necessary and appropriate in the circumstances, including but not limited to:

1. Require a remedy to the condition or situation.

2. Require work to shut down until the condition or situation is remedied.

3. Terminate subcontractor without further liability with termination terms according to agreement.

Company Name:*

Representative Name:*

First NameLast Name

Representative Tite:*

Signature*

Date of Acknowledgment*

Date

Subcontractor Prequalification Questionnaire

1. Company Information:

2. Work Experience and Specialtize:

3. Safety Policies and Standards:

4. Safety Training and Procedures:

5. Emergency Plans:

6. Protective Equipment Usage and Maintenance:

7. Incident Reporting Protocols:

8. Compliance with Government Regulations / Insurance:

9. Additional Information:

Subcontractor Safety Acknowledgement