Document 0qgqXXdZ78KOZ1MoJLoj7v2BM

APPENDIX ^.0 (M v <=- ' 3'* . ~ <3? /{. //ft"1 r*1 ------------------^ ^ /-C"--' y' ITEMS FOR INCLUSION IN CONTRACTOR PRE-QUALIFICATION AND QUALIFICATION FORMS g1. List your firm's Interstate Experience Modification Rate for the three most rreeccepnntt yveeaarrss. ' 19 19_ 19 2. Please use your last year's OSHA No. 200 Log to fill in: Number of injuries and illnesses: a) Number of lost workday cases b) Number of restricted workday cases c) Number of cases with medical treatment only d) Number of fatalities 3. Employee hours worked last year (do not include any nonwork time, even though paid). 4. Are accident reports and report summaries sent to the following? How often? No Yes Monthly Quarterly Annually Field Superintendent ____ _____ ________ __________ _________ Vice Pres, of Construction ____ _____ ________ __________ _________ President of Firm ____ _____ ________ __________ _________ 5. Do you hold site safety meetings for field supervisors? YesNoHow Often? 6. Do you conduct project safety inspections? YesNo If yes, who conducts this inspection (title)? And how often? SC 000389 LAM001586 7. How are accident records and accident summaries kept7 How often are they reported? Accidents totaled for the entire company No ______ Yes _____ Frequency __________ Accidents totaled by project ______ _____ __________ - Subtotaled by superintendent ______ _____ __________ - Subtotaled by foreman ______ _____ __________ 8. How are the costs of individual accidents kept? How often are they reported? No Yes Frequency Costs totaled for entire company ______ _____ __________ Costs totaled by project ______ _____ __________ - Subtotaled by superintendent ______ _____ __________ - Subtotaled by foreman ______ _____ __________ 9. List key personnel planned for this project. Please list names, expected posi tions and safety performance on last three projects worked on. 10. Do you have a written safety program? YesNo Provide one copy with bid proposal. 11. Do you have a safety orientation program for new hires? YesNo ____ 12. Do you have a safety orientation program for newly hired or promoted foreman? No Yes 13. Do you hold craft "toolbox" safety meetings? Yes No How often? Completed by Firm Name Telephone Date TTtTi----------- 2- - sc 000390 LAM001587