/ USAContractor HSE Pre-Qualification Form
HSE-FRM-009 / Rev.03/20/13
GENERAL INFORMATION
Company Name: / Telephone Number:
Fax Number:
E-mail Address:
Street Address: / Remittance Address:
Province/State: / Postal/Zip Code: / Province/State: / Postal/Zip Code:
How many years has your organization been in business under your present firm name?
Previous name of firm (if applicable):
Contact For / Name / Phone / Email
Primary Information
Bid Purposes
HSE Purposes
ORGANIZATION
Describe Services Performed:
Construction
Construction Design
Maintenance
Personnel and Resources
Drilling / Original Equipment Manufacturer/Installer
Original Equipment Manufacturer/Maintenance
Project Maintenance Service Work (Janitorial, Clerical, etc.)
Production
Other
Describe Additional Services Performed:
List other types of work within the services you normally perform that you subcontract to others, including brokers:
Describe any affiliations with labour organizations. (include copies of collective agreements)
Annual Dollar Volume for the Past Three Years: / (yyyy) / (yyyy) / (yyyy) / Largest Job During the Last Three Years:
Over $10 Million /
$1 mil to $10 Million
$100,000 to $1 Million
Under $100,000
Your Firm’s Desired Project Size: / Maximum: / Minimum:
COMPANY WORK HISTORY
Major Jobs in Progress:
Customer/Location / Type of
Work / Size
$M / Customer
Contact / Telephone / Fax
Major Jobs Completed in the Past Three Years:
Customer/Location / Type of
Work / Size
$M / Customer
Contact / Telephone / Fax
HEALTH , SAFETY AND ENVIRONMENT MANAGEMENT
Highest ranking HSE professional in your organization:
Name: Telephone:
Email: / Qualifications:
CRSP CHSC CET ASP
ROH NCSO P. Eng
CSP Trade Cert Other
Do you have or will you provide:
  • A full-time Health, Safety and Environment representative? Yes No
  • A full-time on site Health, Safety and Environment representative? Yes No

On site HSE representative for the duration of work.
Name: Telephone:
Email: / Qualifications:
CRSP CHSC CET ASP
ROH NCSO P. Eng
CSP Trade Cert Other
Has any employee been barred from working on any site as a Supervisor, Foreman, or Project Manager due to Health, Safety and Environmental issues? Yes No
HEALTH, SAFETY AND ENVIRONMENT PERFORMANCE
This Section must include all Subcontractor Injury Statistics in combination with your Company's Performance
Your Worker Compensation number: / Industry code:
From the last three years : / 2009 / 2010 / 2011
  • Your Industry Premium Rate?

  • Your Industry Rate Adjustment %?

  • Surcharge or Discount?

  • Employers' Premium Rate?

  • Number of fatalities?

  • Number of lost time accidents? (LT)

  • Number of days lost?

  • Number of medical aid injuries? (MA)

  • Number of first aid injuries?

Exposure hours worked including subcontractors / Field Hours
Total Hours
  • Total Recordable Incident Frequency? (TRIF)

  • Lost Time Incident Frequency? (LTIF)

  • Severity rate?

Calculation: TRIF = (# MA + # LT) x 200,000 LTIF = # LT x 200,000 Severity = LT days x 200,000
Exposure Hours (Field) Exposure Hours (Field) Exposure Hours (Field)
Have you been cited, charged, or prosecuted for any Occupational Health & Safety non-compliance or Environmental Offense in the last three years? Yes No
If Yes, give details:
Has your company ever been prosecuted for an Environmental offense/issued with a stop order by or from a Government regulatory agency? Yes No
If Yes, give details:
Is your company capable of identifying all hazardous wastes that may be used or encountered during this work? Yes No
Will your company provide MSDS’ for all controlled products used on site? Yes No
Is your company aware of the Government and legal requirements required for the disposal of any of these Hazardous Wastes that may be encountered during this work? Yes No
HEALTH , SAFETY AND ENVIRONMENT PROGRAM or SYSTEM AND PROCEDURES
Do you have a written Health, Safety and Environment MS/Program? Yes No
Does the program/system address the following key elements:
  • Accountabilities and responsibilities for managers, supervisors, and employees? Yes No
  • Employee participation? Yes No
  • Hazard recognition and control? Yes No
  • Management commitment and expectations? Yes No
  • Periodic Health, Safety and Environment performance appraisals for all employees? Yes No
  • Resources for meeting Health, Safety and Environment requirements? Yes No
  • Supervisor & Employee Training? Yes No
  • Safety Meetings and Communications? Yes No

Does the program/system include Safe Operating Practices and Plans such as:
  • Incident Reporting?Yes No
  • First Aid Log Completion?Yes No
  • Modified Work Program/Medical Accommodation Program?Yes No
  • Compressed Gas Cylinder Handling?Yes No
  • Confined Space Entry?Yes No
  • Assured Grounding Program?Yes No
  • Emergency Preparedness, including an Evacuation Plan?Yes No
  • Equipment Lockout and Tag Out (LOTO)?Yes No
  • Fall Protection?Yes No
  • Housekeeping?Yes No
  • Personal Protective Equipment (PPE)?Yes No
  • Portable Electrical/Power Tools?Yes No
  • Powered Industrial Vehicles (cranes, forklifts, JLGs, scissor lifts, etc.)?Yes No
  • Unsafe Condition Reporting?Yes No
  • Vehicle Safety? (i.e. Defensive Driving)Yes No
  • Field Level Risk Assessment?Yes No
  • Craning/Rigging/Lifting?Yes No
  • Scaffolding?Yes No
  • Hot Work and Fire Prevention?Yes No

Do you have written programs for the following:
  • Hearing Conservation?Yes No
  • Respiratory Protection?Yes No
Where applicable, have employees been:
Respirator Fit Tested? Yes No
Trained in use of RPE? Yes No
  • WHMIS?Yes No

Do you have a Substance Abuse Policy? Yes No
If yes, does it include the following:
  • Site Access? Yes No
  • Pre-employment? Yes No
  • Testing for Cause? Yes No

Medical:
Do you conduct medical examinations for:
  • Pre-employment?Yes No
  • Pulmonary function testing?Yes No
  • Hearing?Yes No
  • Vision?Yes No
Do you have personnel trained to perform First Aid and CPR? Yes No
Do you hold documented site Health, Safety and Environment meetings for:
  • Employees? Yes NoFrequency:
  • Field Supervisors? Yes NoFrequency:
  • New Hires? Yes NoFrequency:
  • Subcontractors? Yes NoFrequency:

Personal Protection Equipment (PPE):
Is applicable PPE provided for employees? Yes No
Do you have a program to ensure PPE is inspected and maintained? Yes No
Do you have a corrective action process for addressing individual Health, Safety and Environment performance deficiencies? Yes No
Equipment and Materials:
  • Do you maintain a list of the major equipment (e.g., cranes, forklifts, JLGs) your company has available for work at this site, and the method of establishing the competencies to operate this equipment? Yes No
  • Do you conduct inspections on operating equipment (e.g., cranes, forklifts, JLGs, etc.) in compliance with the regulatory requirements? Yes No
  • Do you have a system for establishing the applicable Health, Safety and Environmental specifications for the acquisition of materials and equipment? Yes No
  • Do you maintain operating equipment in compliance with manufacturer’s and local legislativerequirements? Yes No
Do you maintain the applicable inspection and maintenance certification records for operating equipment? Yes No
Subcontractors:
Do you evaluate the ability of subcontractors to comply with applicable Health, Safety and Environment requirements as part of the selection process? Yes No
Do you include your subcontractors in:
  • Audits?Yes No
  • Health, Safety and Environment Meetings?Yes No
  • Health, Safety and Environment Orientation?Yes No
  • Inspections?Yes No
  • Do your subcontractors have a written Health , Safety and Environment Management Program or System?Yes No
Do you use Health , Safety and Environment performance criteria in the selection of subcontractors? Yes No
HEALTH , SAFETY AND ENVIRONMENT TRAINING
Health, Safety and Environment Orientation Program: / New Hires / Supervisors
  • Do you have a Health, Safety and Environment Orientation for new hires and newly hired or promoted supervisors?
  • Does this process provide instruction on the following:
  • Emergency Procedures?
  • Fire Protection and Prevention?
  • First Aid and CPR Procedures?
  • Incident Investigation?
  • Refusal to Work?
  • Safe Work Permits & Practices?
  • Personal Protective Equipment use?
  • Supervisors Responsibility?
  • Toolbox Meetings?
  • WHMIS Training?
  • Field Level Risk Assessment?
  • Confined Space?
  • How long is the orientation process?
/ YesNo
Hours / YesNo
Hours
Trade Training:
  • Are employees’ job skills certified, where required, by
regulatory or industry consensus standards? Yes No
  • Have employees been trained in the appropriate job skills?Yes No
  • Are operators licensed and/or certified to operate the equipment used? Yes No
  • Have your employees completed CSTS, OSHA 10 or an Industry specific equivalent?
Yes No
List crafts which have been certified:
Health, Safety and Environment Training Program:
  • Do you have a specific Health, Safety and Environment Training Program for supervisors?
Yes No
  • Do you know the regulatory Health, Safety and Environment training requirements for your employees? Yes No
  • Have your employees received the required Health, Safety and Environment training and retraining?
Yes No
Training Records:
  • Do you have Health, Safety and Environment and craft-specific training
records for your employees? Yes No
  • Do the training records include the following:
  • Date of Training? Yes No
  • Employee Identification? Yes No
  • Method Used to Verify Understanding? Yes No
  • Name of Trainer? Yes No
  • How do you verify understanding of the training?(Check all that apply)
Job Monitoring
Oral Test
Performance Test
Written Test
Other (List)
Inspections and Audits:
Are corrections of the deficiencies documented? Yes No
  • Do you conduct Health, Safety and Environment inspections? Yes No
How often?
  • Do you conduct Health, Safety and Environment Management Program audits? Yes No
How often?
INFORMATION SUBMITTAL
Note: Copies of the following information must be returned in conjunction with this Form.
No. / Records, Statements or Forms
1. / Certificate of Recognition within the last three years.
2. / Worker Compensation certificate, affidavit, or letter of compliance (dated within the last three months).
3. / An inventory (list) of job specific work practices and procedures related to your work activities.
4. / A one-page sample of your safety training records.
5. / A one-page outline of your Employees & Supervisor Health , Safety and Environment Training program.
6. / A one-page outline of your employee Job Site Health, Safety and Environment Orientation.
7. / A one-page sample of a completed Employer's OHS First Aid Log (Names should be blacked out).
8. / A sample of a completed Incident Form.
9. / A sample of an employee Modified Work Form with Supervisor / Management approval section.
10. / A sample of a completed Hazard Assessment.
11. / A sample of a completed Field Level Risk Assessment.
12. / A sample of a completed HSEPlanned Inspection Report Form.
13. / A sample of Equipment Inspection and Materials Inspection Form(s) with a deficiency notification to client section.
14. / A one-page schedule of your employee Health, Safety and Environment Meetings and Scheduled Topics.
15. / A copy of your Substance Abuse Policy.
16. / A one page Summary of your Company's Health, Safety and Environment Performance Improvement.
By signing this form I certify that the attached information is correct.
SIGNATURES REQUIRED
Senior Contractor Representative / Title and Telephone Number: / Signature
Contractor HSE Representative / Telephone Number: / Signature
USA HSE Contractor Pre-Qualification Form / “Road to Zero” / Uncontrolled When Printed
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This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to ensure compliance.