55428 Contractor Questionnaire:

Title Page

GENERAL INFORMATION

Indicate current number of employees
Indicate number of peak vs. non-peak employees
Indicate whether this a union shop?
Indicate if there are:
Night Workers
24/7 Exposure
Indicate type of work that is subcontracted:
Indicate typical bid type (e.g. low bid, fixed price, cost-reimbursement, etc.)
Does applicant's management have defined roles and responsibilities for the following:
Safety
If yes, is compensation tied to performance?
Quality
If yes, is compensation tied to performance?
Does the applicant use the following substance abuse prevention practices?
Pre-hire drug screen
Post-accident drug and alcohol testing
Random drug testing
For-cause drug testing
Substance abuse recognition training
Program compliant with state specific laws

Indicate the name, title, phone number and e-mail address of the person responsible for reporting and tracking claims:
Name
Title
Phone Number
E-mail Address
Does applicant use the following risk management practices?
Risk Manager
Safety Professional
Safety Meetings
If yes, indicate how often they are held?
Hazard analysis program (e.g. JHA, SHA, AHA, etc.)
Formal accident investigations
If yes, conduct formal lessons learned?
Does the applicant have any of the following exposures?
Asbestos
Blasting
Crane
If yes, does applicant have a formal crane management program?
If yes, does contractor rent or loan cranes to others?
If yes, are crane operators, riggers and signalers trained with certifications maintained?
Demolition
Lead, cadmium and/or silica
Pile driving
Tunneling
Work over navigable water
Does applicant have a written equipment maintenance program?
If yes, is there a written inspection program?
If yes, is there a written corrective action program?
Does applicant use the following traffic control and jobsite security practices?
Subcontract traffic control
Controlled jobsite entrance/exits
Certified/trained flaggers
Method for controlling internal jobsite traffic
Photographic documentation of traffic controls
Written procedure for jobsite security
Does applicant use the following environmental controls?
Written environmental control program
If yes, is there a containment plan?
If yes, is there a storm water prevention plan (SWPP)?
If yes, is there a spill reporting and clean-up plan?

Indicate the name, title, phone number and e-mail address of the person responsible for reporting and tracking claims:
Name
Title
Phone Number
E-mail Address
Does the applicant have a written fleet management program?
If yes, does it include vehicle maintenance requirements?
Does applicant use the following driver selection practices?
Motor Vehicle Records (MVR) checked with set criteria prior to hire
MVR’s verified at least annually
Formal driver training program
Are employees allowed to use company vehicles for personal use?
Does applicant transport employees to and from job sites?
If yes, indicate vehicle type, maximum number of passengers and maximum distance traveled:
Does application have a cell phone use policy?
Are company vehicles equipped with telematics?

Does applicant use the following employee selection, orientation and training practices?
Formal application process
References/background process
Written job descriptions
Employee Handbook
Formal orientation program
Formal mentoring program
Documented disciplinary procedures
Does applicant use the following soft tissue injury prevention practices?
Stretch and flex programs
Soft tissue injury awareness training
Ergonomic tool selection and purchase program
Indicate the name, title, phone number and e-mail address of person responsible for managing the RTW program:
Name
Title
Phone Number
E-mail Address
Does applicant use the following return-to-work (RTW) practices
Written RTW program
RTW program consistently applied to all employees
Supervisors involved in RTW process
Preferred provider organization (PPO) network

Does application use the following fall management practices
Written fall management program
Indicate at what height 100% fall protection is required
Does the applicant use the following slip, trip and fall (STF) prevention practices?
Written STF program
Housekeeping program
Periodic documented inspections
Photo documentation of perimeter controls
Does applicant have a silica control program?
If yes, indicate how often and who conducts the training
General Liability:
Indicate the name, title, phone number and e-mail address of person responsible for managing quality program:
Name
Title
Phone Number
E-mail Address
Does applicant use the following quality management practices?
Written quality management program
If yes, does it include water infiltration and mold prevention?
If yes, does it include records retention process?
Pre-planning meetings
Material verification
Third-party inspections
Method for tracking corrective actions
Pre-closure photo documentation process
Documented warranty procedures
Does applicant provide snow removal services?