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CONTRACTOR'S PRE-QUALIFICATION QUESTIONNAIRE
Contractor's name______________________________________________________SIC Code_______
Address_____________________________________________________________________________
SAFETY, HEALTH AND ENVIRONMENTAL PRACTICES
1. Describe your safety organization (Staff, outside consultants etc.)_____________________________
2. Do you have a current written safety program?____________
3. Are your current employees trained in all aspects of the above safety program? __________________
Describe how the training is provided and the frequency of updates____________________________
ACCIDENT REPORT RESULTS
1. Please use your most recent three (3) years OSHA LOG to complete:
a. Total number of injuries and illness --------------------------------- _____ _____ _____
b. Total number of cases involving days away from work----------- _____ _____ _____
c. Total number of cases involving days of restricted work--------- _____ _____ _____
(Changes format to meet 2002 reporting criteria for year after 2002)
2. List and describe all serious OSHA citations your firm has had in the last three (3) years.
3. Who is your current workers' compensation insurance carrier?____________________________
4. How long have you been covered by this carrier? ______________________________________
5. What is your current Experience Modification Rating (E.Mod.) ___________________________
6. Have you ever performed any work with our company in the past? ____ If yes, describe date, location
and type of work performed.________________________________________________
_________________________________________________________________________________
Signature of person submitting data: _____________________________ Date ___________________
Name and job title_____________________________________________________________________
(Please print)
