1. Subcontractor Information
Contractor / Company name:
Street address:
Street address 2:
City:
State/Province:	- Select one - Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maine Maryland Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip code:
Country:
Office phone:
FAX number:
Website:

Company's Corporate Safety Representative
Job title:
First name:
Last name:
Cell phone:
Email address:
	Safety & Health Performance

2. Safety & Health Performance
Please provide the following safety statistics. Attach copies of your OSHA Injury/Illness Logs for the previous three years and the current year-to-date. Also, attach a copy of a statement from your Worker's Compensation insurance carrier indicating your Experience Modification Rating (EMR)
	2007	2008	2009	Current Y-T-D
1. Number of Recordable Cases
2. Number of Lost Work Day Cases
3. Number of Restricted Work Day Cases
4. Number of Medical Only Cases
5. Number of Lost Work Days
6. Number of Lost Work Days
7. Number of Restricted Work Days
8. Total Recordable Incident Rate
9. L.T.R.I.R.
10. R.W.C.R.I.R.
11. DART
12. EMR
13. Average Number of Employees
14. Man Hours Worked
Has your company been cited by any regulatory agency (OSHA, MSHA, EPA, etc.), in the last three years? (If yes, please submit copies of the citation(s), date(s) and final resolutions). Yes No
	Safety & Health Programs & Procedures

3. Safety & Health Programs & Procedures
Does your company use subcontractors?		Yes No
Does your company evaluate a subcontractor's safety performance and programs prior to hiring?		Yes No
(If yes how?)
Does your company have a written Environmental, Health & Safety Programs?		Yes No
Does your company have a Substance Abuse Program? (If yes, please submit a copy on signature page)		Yes No
Does your Substance Abuse Program include the following:
Pre-Employment Testing		Yes No
Random Testing (If yes, how often?)		Yes No
Testing for Cause		Yes No
Post Incident Testing		Yes No
Do you conduct on site drug screening?		Yes No

"Safety & Health Programs & Procedures (2)

4. Safety & Health Programs & Procedures (2)

Does your program include practices and procedures for the following:

Safety Orientation	Yes No N/A		Personal Protective Equipment	Yes No N/A
Safety Meeting	Yes No N/A		Respirator Protection	Yes No N/A
Accident / Incident Reporting	Yes No N/A		Hearing Conservation	Yes No N/A
Safety Audits	Yes No N/A		Fall Protection	Yes No N/A
Medical Treatment	Yes No N/A		Ladders	Yes No N/A
Drug / Alcohol Use	Yes No N/A		Scaffolding	Yes No N/A
Vehicle Safety	Yes No N/A		Hazard Communications	Yes No N/A
Forklift Safety	Yes No N/A		Barricade	Yes No N/A
Crane Safety	Yes No N/A		Housekeeping	Yes No N/A
Man Lift Procedures	Yes No N/A		Fire Protection	Yes No N/A
Scissor Lift Procedures	Yes No N/A		Emergency Procedures	Yes No N/A
Hand Tools	Yes No N/A		Trenching / Excavation	Yes No N/A
Power Tools	Yes No N/A		Rigging /Lifting	Yes No N/A
Permits	Yes No N/A		Confined Space	Yes No N/A
Spill Prevention	Yes No N/A		Electrical Safety	Yes No N/A
Waste Disposal	Yes No N/A		Arc Flash NFPA 70E	Yes No N/A
Hot Work	Yes No N/A		Lockout / Tagout / Try Procedures	Yes No N/A
First Aid / CPR / Blood Borne	Yes No N/A		Welding / Cutting	Yes No N/A
MSDS	Yes No N/A		JSTA / STA TA	Yes No N/A

Safety & Health Programs & Procedures (3)

5. Safety & Health Programs & Procedures (3)

Who conducts on site drug screening?

List all drug screening training the assigned on site competent person has received:

Does Your Company have a Disciplinary Action Program? (If yes, please submit a copy)	Yes No
Will you provide a full time Safety Director on site?	Yes No
(If awarded contract, a resume will need to be submitted two weeks prior to the start of the contract)
Are site safety inspections / audits conducted? (If yes, please submit a copy on signature page)	Yes No

Who Conducts the inspection / audits?

How often are site inspections / audits conducted?

Who conducts accident / incident investigations?

Who is the accident / incident investigation information shared with?

How frequently is this information released?

Safety & Health Training

6. Safety & Health Training
Does your company conduct safety orientations: (If yes, please submit a copy of the orientation sheet on signature page)	Yes No

What is the length of time for your safety orientations?

What is the duration of your safety training?

Is your management staff current with First Aid / CPR / Blood Borne Pathogens?	Yes No
Is your field management staff OSHA 10 Hour trained? (If yes, how many?)	Yes No

Do you hold site safety meetings for:
Supervisors	Yes No		Frequency:
Field Employees	Yes No		Frequency:
Subcontractors	Yes No		Frequency:

Signatures & Attachments

7. Signatures & Attachments

By submitting this form, the undersigned certifies:
That he / she has been authorized by the affected contractor to execute this questionaire.
That he / she has read this questionaire and reviewed the information provided in reponse thereto,
and that the information is true and accurate as of the date indicated below.
That the foregoing information is being provided by or on behalf of the affected contractor with the
understanding that Fagen, Inc. will use it in deciding whether or not to enter into contracts with them.

Please print this page sign and attach electronic copy.

________________________________________ Contractor's Representive Signature

_______________________ Date

_________________________________________ Contractor's Representive Name (type or print)

_______________________ Date

Please attach copies of checked items with the completed PQF:

EMR documentation from your insurance carrier
OSHA 300 Logs (past three years)
Safety & Health Program
OSHA, MSHA, EPA Citations (Past three years)
Substance Abuse Program
Disciplinary Action Program
Accident / Incident Investigation Procedure
Safety & Health Inspection Audit Form
Safety Orientation
Signature Page