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 Information2Work Performed3Safety Performance4Safety Process5Safety Management6JHA & Control7Medical Management8Alcohol/Substance9Security10Training and Qualifications11Additional Information Company InformationFederal Employer Identification Number (FEIN)*Date business founded or incorporated* MM slash DD slash YYYY Company Legal Name*DBA:Union* Yes No Qualification completed by:* Main Office Branch Office Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*FaxSIC or NAICS code:*Preferred Company Contact Name:* First Last Contact Title:*Email* Moretrench person who requested you to complete qualification process? Type(s) of work performed by Company:Do you operate DOT regulated Commercial Motor Vehicles?* Yes No If yes, provide DOT number:*Do you work at MSHA covered sites?* Yes No If yes, provide MSHA Contractor ID:*Services Performed*Select from drop-down menu AnalysisBarge ServicesChemical Grouting & Pipe SealingConcrete PumpingCore Construction, Inc./Waterside West Apartment BuildingsCoring & CuttingCrane and Rigging OperationsDebris RemovalDewateringDiesel Engine ServiceDivingDrilling ServicesEcosystem RestorationEHS EngineeringElectrical ContractingElectrical ServicesEquipemnt RentalsEquipment MaintenanceEquipment RentalsErecting ContractingExcavationFencingFilterpointFire Protection SystemsFlag & BannersFleet FuelingGeneral ContractingGeotechnical EngineeringHeat TreatmentHorizontal DrillingIndustrial CoatingsLandscaping EquipmentLaundry ServiceLiner RecyclingMaintenance ServicesNutrien White SpringsPavingPilingPipe FusionPipeline RepairPipeline ServicesPlumbing SupplyRefuse SystemsRiggingScaffoldingShoringSoil ManagementStabilizationStaffingSubdivisions/ApartmentsSURFACE PREPARATION & ABATEMENTSurvey & MappingTractor ServiceTruckingUnderground UtilityUtility LocatingWaste SystemsWeld InspectionOtherList Clients/Client Sites where you have worked in the past year:Column 1 Add RemovePerson directly responsible for safety:* First Last Title*Email* II Safety PerformanceOSHA 300 LOGS & 300A SUMMARYUpload: 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 Select files 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 Select files Max. file size: 108 MB, Max. files: 3. A) Number of Cases from OSHA Forms 300 LOG & 300A SUMMARYTotal number of deaths (G).This field is hidden when viewing the form2026 Total number of deaths YTDThis field is hidden when viewing the form2025 Total number of deaths YTD2024 Total number of deaths YTD*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).This field is hidden when viewing the form2026 Total number of cases with days away from work YTDThis field is hidden when viewing the form2025 Total number of cases with days away from work YTD2024 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).This field is hidden when viewing the form2026 Total number of cases with job transfer or restriction YTDThis field is hidden when viewing the form2025 Total number of cases with job transfer or restriction YTD2024 Total number of cases with job transfer or restriction YTD*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).This field is hidden when viewing the form2026 Total number of other recordable cases YTDThis field is hidden when viewing the form2025 Total number of other recordable cases YTD2024 Total number of other recordable cases YTD*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).This field is hidden when viewing the form2026 Total number of days away from work YTDThis field is hidden when viewing the form2025 Total number of days away from work YTD2024 Total number of days away from work YTD*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).This field is hidden when viewing the form2026 Total number of days of job transfer or restriction YTDThis field is hidden when viewing the form2025 Total number of days of job transfer or restriction YTD2024 Total number of days of job transfer or restriction YTD*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 & 300AAnnual average number of employeesThis field is hidden when viewing the form2026 Annual average number of employeesThis field is hidden when viewing the form2025 Annual average number of employees2024 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.This field is hidden when viewing the form2026 Total hours worked by all employees YTDThis field is hidden when viewing the form2025 Total hours worked by all employees YTD2024 Total hours worked by all employees YTD*2023 Total hours worked by all employees*2022 Total hours worked by all employees*2021 Total hours worked by all employees*D) Total Recordable Injury Rate (TRIR) Rate Calculated2024 TRIR rate{Total of G, H, I & J x 200,000 / Total hours worked by all employees in year}. TRIR Calculated 2023 TRIR rate{Total of G, H, I & J x 200,000 / Total hours worked by all employees in year}. TRIR Calculated2022 TRIR rate{Total of G, H, I & J x 200,000 / Total hours worked by all employees in year}. TRIR Calculated 2021 TRIR rate{Total of G, H, I & J x 200,000 / Total hours worked by all employees in year}. TRIR Calculated E) Days Away, Restricted, or Transferred (DART) Rate Calculated2024 DART rate YTD Lost time injury rate {Total of H & I x 200,000 / Total hours worked by all employees in year}. DART Calculated 2023 DART rate Lost time injury rate {Total of H & I x 200,000 / Total hours worked by all employees in year}. DART Calculated2022 DART rate Lost time injury rate {Total of H & I x 200,000 / Total hours worked by all employees in year}. DART Calculated2021 DART rate Lost time injury rate {Total of H & I x 200,000 / Total hours worked by all employees in year}. DART Calculated F) Additional InformationUpload: EMR letter from insurance carrier that includes EMR for calendars years 2021 - 2024* Drop files here or Select files Max. file size: 108 MB, Max. files: 4. 2024 Insurance Experience Modifier Rate (EMR).*2023 Insurance Experience Modifier Rate (EMR)*2022 Insurance Experience Modifier Rate (EMR).*2021 Insurance Experience Modifier Rate (EMR).*OSHA Citations2024 Number of OSHA citations.*2023 Number of OSHA citations.*2022 Number of OSHA citations.*2021 Number of OSHA citations.*MSHA Citations2024 Number of MSHA citations.*2023 Number of MSHA citations.*2022 Number of MSHA citations.*2021 Number of MSHA citations.*DOT Citations2024 Number of DOT citations.*2023 Number of DOT citations.*2022 Number of DOT citations.*2021 Number of DOT citations.*EPA Citations2024 Number of EPA citations.*2023 Number of EPA citations.*2022 Number of EPA citations.*2021 Number of EPA citations.* III Safety ProcessA) Contractor Prequalification Questions1) Are you a member of ISNetworld?* Yes No Enter ID*Are you a member of Avetta (formerly PICS)?* Yes No Enter ID* B) Safety Management1) Do you have a formal, written, safety document which defines your company’s safety management system, program or process?* Yes No 2) Do you have full time safety professional(s)?* Yes No If no, do you appoint Site Safety Officers?* Yes No 3) Do you have an employee safety manual?* Yes No Upload Safety Manual* Drop files here or Select files Max. file size: 108 MB, Max. files: 2. 4) Do you hold regularly scheduled, documented, safety meetings for employees?* Yes No If yes, how often?* Start of Each Task Daily Weekly Monthly Other 5) Do you have a behavioral based safety process?* Yes No 6) Do you conduct investigations/analyses for all events such as injuries, property damage, near-misses and environmental spills?* Yes No 7) Do you have a New Hire or Short Service Employee (SSE) policy or program* Yes No If yes, how many days do employees stay on probation or in the SSE program?*8) Do your employees have STOP Work Authority?* Yes No If yes, is STOP Work Authority documented?* Yes No 9) Do you have a formal, written, employee discipline policy?* Yes No 10) Do you have a employee safety recognition program?* Yes No C) Job Hazard Analysis And Control1) Do you require a permit or other form of approval process for all work performed?* Yes No 2) Do you utilize pre-task hazard assessments prior to the start of each and every task?* Yes No 3) Do you utilize Job Safety Analysis (JSA) or other similar hazard identification processes?* Yes No 4) Do you conduct documented field safety audits/inspections to determine compliance with applicable federal, state, local and company regulations/procedures?* Yes No D) Medical Management Of Work Related Injuries And Illnesses1) Do you use a specific clinic or doctor to see for treatment?* Yes No If yes, please provide name of primary clinic or physician:*2) Are injured employees required to report injuries and illnesses immediately, regardless of severity?* Yes No 3) Are injured employee required to be accompanied by a representative of management when they report to a heath practitioner/doctor/clinic/hospital for treatment?* Yes No If yes:* Initial visit All visits 5) Do you actively pursue the return to work of injured employees?* Yes No 6) Does your field supervision have an understanding of what constitutes an OSHA recordable injury?* Yes No 7) Do you provide trained First Aid and CPR providers for each work site?* Yes No E) Alcohol/Substance Abuse Programs1) Do you have a written alcohol/substance abuse screening/testing program for all employees?* Yes No 2) Do you perform alcohol/substance abuse screening?* Yes No Check that Apply* New Hires Random Periodic Probable Cause Post Event Select All3) Do you have a written alcohol/substance abuse screening/testing program for DOT covered employees?* Yes No 4. Do any employees have current Substance Abuse cards issued by independent organizations?* Yes No Check that Apply DISA CCS (formerly MICCS) Select All F) Security1) Does your company conduct employee background investigations?* Yes No If yes, when are background investigations conducted:* New Hires Periodic Probable Cause Other Select All2) Do any employees have Transportation Employee Identification Cards (TWIC)?* Yes No G) Written Programs and Training and Qualifications1) Do you have a documented new employee safety & health orientation program?* Yes No If yes, how many hours of orientation do newly hired employees attend?*2) Do you employ crane operators?* Yes No If yes, are crane operators NCCCO certified?* Yes No 3) Check topics below to indicate which topics you provide documented employee training* Florida Phosphate Producers (FPP) Basic Alliance Safety Council Basic Orientation Plus Duke Energy PowerSafe Tampa Electric Safety & Security Orientation MSHA Part 46 Miner Training MSHA Part 48 Miner Training OSHA 10 Hour Construction OSHA 30 Hour Construction Water Safety Trenching and Excavating Confined Space Entry Process Safety Management Energy Isolation (Lockout/Tagout) Fall Protection Hazard Communication Hearing Protection Respiratory Protection Rigging Scaffolding Additional Information or CommentsCommentsAdditional InformationRE: OSHA 2024 Logs year-to-dateAdditional Information File UploadRE: OSHA 2024 Logs year-to-date Drop files here or Select files Max. file size: 108 MB. As the designated representative of our company, I certify that we agree to follow the rules and requirements set forth in Company EHS policies and procedures.Name* First Last Email*Copy of Application will be sent to this email Signature
