Application For Bidder Selection
Appendix 3 – Health and Safety Questionnaire
Package Number: CD0510-001
APPENDIX 3
HEALTH AND SAFETY QUESTIONNAIRE
Package Number: / CD0510-001Package Name: / Supply and Install Permanent Communications Systems, Optical Transport Network (OTN)
Applicant:
Applicant Name:
Contact Phone: / Email:
LCP-PT-MD-0000-SC-FR-0050-01 Rev. B1
Application For Bidder Selection
Appendix 3 – Health and Safety Questionnaire
Package Number: CD0510-001
TABLE OF CONTENTS
1.0 INTRODUCTION 3
2.0 QUESTIONNAIRE Instructions 3
2.1 EMPLOYEE/PERSON HOURS 3
2.2 WORKERS COMPENSATION 3
2.3 REGULATORY COMPLIANCE 4
3.0 HEALTH AND SAFETY Record 4
4.0 Leadership and Administration 5
5.0 Leadership Training 5
6.0 Accident / Incident Investigations 5
7.0 Emergency Preparedness 5
8.0 Organizational Rules, Policies and Procedures 5
9.0 Employee Knowledge and Skills Training 5
10.0 Personal Protective Equipment 6
11.0 Group Meetings 6
12.0 HAZARD IDENTIFICATION AND RISK CONTROL 6
13.0 PLANNED Health and SAFETY AUDITS AND INSPECTIONS 6
1.0 INTRODUCTION
Nalcor places the highest priority in having a safe and healthy workplace for employees and contractors’ employees. Nalcor’s commitment is to be an industry leader in Health and Safety Standards in all areas of our work, and thereby achieve an accident free and healthy workplace.
To accomplish this, the Lower Churchill Project shall only utilize Contractors / Suppliers who meet or exceed Health and Safety Standards. The Applicant is required to provide the information specified in this Appendix, which is designed to assist Nalcor in evaluating the standard and effectiveness of Applicant’s Health and Safety Management Systems.
2.0 QUESTIONNAIRE Instructions
Please provide responses in the space provided. This completed Health and Safety Questionnaire and supporting documentation should be included in this document.
2.1 EMPLOYEE/PERSON HOURS
Please provide the average number of employees and estimated person hours for the last three years (including subcontractors):Year
Number of Employees
Number of Person hours
2.2 WORKERS COMPENSATION
2.2.1 Which jurisdiction is your company registered in?NL (WHSCC) / Other / Specify
2.2.2 What is your company's National Industry Classification Code (NIC)?
Year
2.2.3 What was your company’s rate per $100 payroll for the past three (3) years?
2.2.4 What was your company’s Experience Rating for years indicated?
2.2.5 What was the industry average for years indicated?
2.3 REGULATORY COMPLIANCE
2.3.1 Please provide the following information on any violations, citations or incidents of compliance experienced during the past three years (including subcontractors).Year
Number of Violations, Citations or Incidents
Number of Agency Inspections conducted
Amount of fines incurred if any
2.3.2 List of Agencies performing inspections:
Please note: The Regulatory Compliance information is to include violations, citations and / or Health and Safety incidents of all contractors and subcontractors while working directly for your company, not just those directly attributed to your company.
3.0 HEALTH AND SAFETY Record
Please provide your company’s Health and Safety record for past three years:
Please perform your calculations using the following formulas:
TRIFR = # (Fat+LTI+MA+RWC) X 200,000Person hours/year / LTIFR = #LTI X 200,000
Person hours/year
Please indicate the answer in the ‘response’ column. If ‘yes’ then provide a reference and attach appropriate documentation or attach explanatory notes / Yes / No / N/A /
4.0 Leadership and Administration
4.1 Does your company’s Health and Safety Program have a Policy Statement that clearly outlines the Company’s commitment to health and safety stewardship?4.2 Is your Health and Safety Program written to a Standard (such as ISO 18001 or CSA Z1000-06)?
5.0 Leadership Training
5.1 Does your company provide formal Health and Safety management training to management personnel?5.2 Does your company provide an overview of training program for management and employees.
6.0 Accident / Incident Investigations
6.1 Does your company have a written procedure for incident/accident reporting and investigation?6.2 Does your company incident/accident investigation follow a process such as the “TapRoot” process?
7.0 Emergency Preparedness
7.1 Does your company have an emergency response plan related to its activities and specific locations?7.2 Does your company provide Emergency Response training?
8.0 Organizational Rules, Policies and Procedures
8.1 Does your company have an Alcohol and Drug Policy? Are all employees made aware of this policy and is it enforced?8.2 Do you have a policy pertaining to prohibited items (e.g. knives, firearms)?
8.3 Are all employees made aware of this policy and is it enforced?
8.4 Does your company make reference to following all applicable legislative requirements in the jurisdiction where work is being performed?
9.0 Employee Knowledge and Skills Training
9.1 Does your company provide training for Management and Supervisors in safety management?9.2 Does your company have in place a process to ensure that only competent workers, including supervision, will be used during the operation?
10.0 Personal Protective Equipment
10.1 Does your company have a policy or specific rules with respect to the use of Personnel Protective Equipment (PPE)?10.2 Does your company have in place a formal process for determining personnel protective equipment requirements for its operation?
11.0 Group Meetings
11.1 Does your company hold scheduled safety meetings, such as:Weekly General Safety Meetings for all crew and Weekly Departmental Meetings for each department at the work site?
11.2 Does your company inform workers of their rights to refuse unsafe work?
12.0 HAZARD IDENTIFICATION AND RISK CONTROL
12.1 Does your company conduct Risk Assessments on all critical and non-routine jobs/job functions?12.2 Does your company have in place a Permit To Work system?
13.0 PLANNED Health and SAFETY AUDITS AND INSPECTIONS
13.1 Does your company’s Health and Safety program outline the requirements for Supervisors and Employees to conduct regular inspections of equipment work conditions at the worksite?13.2 Does your company’s Health and Safety program require the prompt reporting of hazardous conditions at the worksite(s)?
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