Subcontractor Safety Qualification Request – SubContractor Qualification

Subcontractor Safety Qualification Request 2.0

Please complete the following information and submit this form and requested submittals to the Safety Department for consideration.

"*" indicates required fields

1Company Information

2Work Performed

3Safety Performance

4Safety Process

5Safety Management

6JHA & Control

7Medical Management

8Alcohol/Substance

9Security

10Training and Qualifications

11Additional Information

Type(s) of work performed by Company:

Do you operate DOT regulated Commercial Motor Vehicles?*

Yes

If yes, provide DOT number:*

Do you work at MSHA covered sites?*

Yes

If yes, provide MSHA Contractor ID:*

Services Performed*

Select from drop-down menu

List Clients/Client Sites where you have worked in the past year:

Column 1

Person directly responsible for safety:*

First Last

Title*

Email*

II Safety Performance

OSHA 300 LOGS & 300A SUMMARY

Upload: OSHA Form 300A, Summary of Work-Related Injuries and Illnesses for past 3 years.*

Upload: OSHA Form 300 Log of Work-Related Injuries and Illnesses with names omitted for past 3 years.

Drop files here or

Max. file size: 108 MB, Max. files: 3.

Upload: OSHA Form 300 with names omitted for past 3 years*

Upload: OSHA Form 300 Log of Work-Related Injuries and Illnesses with names omitted for past 3 years.

Drop files here or

Max. file size: 108 MB, Max. files: 3.

A) Number of Cases from OSHA Forms 300 LOG & 300A SUMMARY

Total number of deaths (G).

2026 Total number of deaths YTD

2025 Total number of deaths YTD*

2024 Total number of deaths*

2023 Total number of deaths*

2022 Total number of deaths*

2021 Total number of deaths

Total number of cases with days away from work (H).

2026 Total number of cases with days away from work YTD

2025 Total number of cases with days away from work YTD*

2024 Total number of cases with days away from work*

2023 Total number of cases with days away from work*

2022 Total number of cases with days away from work*

2021 Total number of cases with days away from work

Total number of cases with job transfer or restriction (I).

2026 Total number of cases with job transfer or restriction YTD

2025 Total number of cases with job transfer or restriction YTD*

2024 Total number of cases with job transfer or restriction*

2023 Total number of cases with job transfer or restriction*

2022 Total number of cases with job transfer or restriction*

2021 Total number of cases with job transfer or restriction

Total number of other recordable cases (J).

2026 Total number of other recordable cases YTD

2025 Total number of other recordable cases YTD*

2024 Total number of other recordable cases*

2023 Total number of other recordable cases*

2022 Total number of other recordable cases*

2021 Total number of other recordable cases

B) Total number of days away from work (K).

2026 Total number of days away from work YTD

2025 Total number of days away from work YTD*

2024 Total number of days away from work*

2023 Total number of days away from work*

2022 Total number of days away from work*

2021 Total number of days away from work

Total number of days of job transfer or restriction (L).

2026 Total number of days of job transfer or restriction YTD

2025 Total number of days of job transfer or restriction YTD*

2024 Total number of days of job transfer or restriction*

2023 Total number of days of job transfer or restriction*

2022 Total number of days of job transfer or restriction*

2021 Total number of days of job transfer or restriction

C) Employment Information from OSHA Form 300 & 300A

Annual average number of employees

2026 Annual average number of employees

2025 Annual average number of employees*

2024 Annual average number of employees*

2023 Annual average number of employees*

2022 Annual average number of employees*

2021 Annual average number of employees

Total hours worked by all employees in year.

2026 Total hours worked by all employees YTD

2025 Total hours worked by all employees YTD*

2024 Total hours worked by all employees*

2023 Total hours worked by all employees*

2022 Total hours worked by all employees*

2021 Total hours worked by all employees