Appendix A

Form 05.01

CONTRACTOR SAFETY AND HEALTH QUALIFICATION FORM

General Electric Company

Global Research

GE USE ONLY
Contractor Qualification Review:  Approved  Not Approved  Class One  Class Two
Date: EHS Review by: Buyer:
Comments:
GE Project Coordinator: ______Phone: ______
1. Contractor Information: Contractor completes this section
Company Name: Number of Employees:
Address: City: State: ZIP:
Standard Industrial Classification (SIC) Code (4 digit) ______or NAICS Code:
Company Contact: Title:
Telephone Number: FAX:
Company Safety Manager/Contact:
Telephone Number: FAX:
Email Address: ______Achieved OSHA VPP STAR: Yes or  No
2. Accidents and Citations: Contractor completes the following sections 2 - 5
YEAR RATE
a. Total OSHA Recordable case rate for each of the last 3 years:
______
b. Total OSHA lost workday case rate for each of the last 3 years:
______
Note: If your company is not required to maintain an OSHA300 log,
Provide your Workers’ Compensation Experience Modification Factor
(EMF) for each of the last three years.
YES NO
c. Has there been a work-related death or multiple  
hospitalizations within the past five (5) years?
(If Yes, Please describe the fatality)
YES NO
d. Has the company received a citation from a regulatory  
agency (OSHA, EPA) within the past five (5) years?
(If Yes, Please explain citation or Attach Documents)

Niskayuna, NY 12309

3. Health and Safety Programs: YES NO N/A
a. Does the company have a written Health and Safety   
Program?
b. Are designated roles and responsibilities assigned   
for health and safety?
c. Does the company have policies and procedures including:
- control of hazardous energy (lockout / tagout)   
- personal protective equipment   
(e.g., respiratory, hard hat, etc.)
- electrical safety/grounding (GFCI)   
- confined space   
- asbestos   
- lead   
- hot work (e.g., welding and cutting)   
- equipment use/inspection   
- excavations/trenching   
- fire prevention   
- hoists   
- housekeeping   
- chemical use, handling and storage   
- work at elevated heights (e.g., scaffolding,   
fall protection, lifts, ladders, etc.)
- work area control and warning signs   
- first aid, medical services and emergency   
procedures
- accident reporting and investigation   
d. Are health and safety training courses   
provided to employees?
e. Are employees adequately trained on company policies   
and procedures? (Frequency: )
f. Are safety meetings (Tool Box Talks) provided on the   
job site? (Frequency: )
g. Are job sites / work areas periodically inspected?   
(Frequency: )
h. The company has a disciplinary policy?   
i. Subcontractors meet acceptable training and safety   
requirements?
Note: GE Global Research provides a one hour on site Contractor Safety orientation
4.  Submittals:
Please provide the following checked documents as part of this qualification form (Below items may be submitted on CD format):
 1. Safety Policy  9. Lockout/Tagout Procedure
 2. Table of Contents of Health and Safety Program  10. Confined Space Entry Procedure
 3. Health and Safety Program  11. Excavation Program
 4. Material Safety Data Sheets (MSDS)  12. Respiratory Protection Program
 5. Hazard Communication Program  13. Asbestos Training Program
 6. Required Waste Disposal Permits  14. Lead Training Program
 7. Fall Protection Systems and Programs  15. Licenses/Registrations: ______
 8. Electrical Safety Training Program  16. Certificate of Insurance
5.  Company Authorization:
Authorizing Agent (Name): Title:
Authorizing Agent (Signature): Date:
Revision Six, Date 12/04
Appendix B (GE USE ONLY)
GUIDE TO DETERMINE FORM 5.01, SECTION 4, REQUIRED SUBMITTALS

Answer each question below and if affirmative, place a check in all corresponding circles to the right.

Questions below - The Contractor will ………..

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15
A. Be a long term resident (i.e., 1 year)? OR / ¡ / ¡
B. Be a non-resident on site intermittently? / ¡ / ¡
C. Work involve construction or demolition? / ¡ / ¡
D. Work primarily in office setting, i.e., software changes, filing, training, etc.? / ¡ / ¡
E. Bring or use any chemicals on site? / ¡ / ¡
F. Generate & be responsible for disposal of waste requiring permits? / ¡
G. Work at elevated heights using lifts, ladders, scaffolds, harnesses? / ¡
H. Work on or in the vicinity of exposed electrical energy at or above 50V? / ¡
I. Work on equipment that must be deenergized to assure safety & sources of energy are more than just cord & plug connected? / ¡
J. Work in confined spaces such as tanks, pits, manholes, etc.? / ¡
K. Work in excavations or trenches more than 4’ below grade or the floor? / ¡
L. Perform any work requiring the use of a respirator? / ¡
M. Perform work that requires removal of or may disturb asbestos? / ¡
N. Perform work that requires removal of or may disturb lead containing materials including paint? / ¡
O. Perform any work that requires a company or its employees to be licensed or registered by NY State? / ¡

NOTES: I. At least one check in each column comprises a requirement for that submittal.

II. These are minimum initial submittal requirements and can be modified by EHS.

SUBMITTALS:

1. Safety Policy 9. Lockout/Tagout Procedure

2. Table of Contents of Health and Safety Program 10. Confined Space Entry Procedure

3. Health and Safety Program 11. Excavation Program

4. Material Safety Data Sheets (MSDS) 12. Respiratory Protection Program

5. Hazard Communication Program 13. Asbestos Training program

6. Required Waste Disposal Permits 14. Lead Training Program

7. Fall Protection Systems & Programs 15. Licenses / Registrations

8. Electrical Safety Training Program 16. Certificate of Insurance

GE Project Coordinator: ______Phone: ______

Contractor Name: Date:

Revision Six, Date 12/04

(GE USE ONLY)