Company Name*
Phone*
Fax*
Email*
Federal ID Number*
Years In Business*
DOT Number*
Contact First Name*
Contact Last Name*
Contact Title*
Safety Contact First Name*
Safety Contact Last Name*
Company SIC Code
SIC Description
Are you a union or non-union contractor?
If you answered "Union" to the previous question, are you a signatory to the PLCA (Pipe Line Contractors Association) agreement?
Upload Disadvantaged Business Enterprise (DBE) Certificate
Upload Woman Owned Business Enterprise (WBE) Certificate
Upload Minority Owned Business Enterprise (MBE) Certificate
Upload Disabled Veteran Business Enterprise (DVBE) Certificate
Number of Exposure or Employee Hours Worked
Number of Fatalities
Number of Cases with Days Away from Work (Lost Time)
Number of Days Away from Work
Number of Cases with Restricted/Job Transfer Work Days
Total Number of "Other" Recordable Cases
Total Number of OSHA Recordable Cases
Lost Time Case (LTC) Rate
Total Recordable Incident Rate (TRIR)
Is your company aware of current air registration requirements for off-road fleet and portable engines?
Does your company carry Worker's Compensation Insurance?
Insurance carriers for the last 3 years
List the Experience Modification (EMR) for your firm for the last 3 years. (Do not include the current year in these numbers.)
Expiration date of current policy
Has your company every been denied coverage by an insurance carrier?
Safety performance information (injury/illness experience) for previous 3 years
Do you have a written safety program?
If yes, does your Safety Program include the following:
New Hire Orientation
Job Site Hazard Analysis/JSA
Drug & Alcohol Testing
Injury Reporting & Emergency Response
Hazard Communications
Fire Safety & Hot Work
Confined Space Entry
Personal Protective Equipment (PPE)
Lock Out / Tag Out
Trenching & Excavation Safety
Material Handling
Fall Protection
Have you submitted a copy of your written safety program?
Upload Written Safety Program
Does your company have a written Management Safety Policy Statement that establishes responsibility and accountability for safety within your company?
Do you have one or more full time:
Safety Professionals?
Environment Professionals or Specialists?
Industrial Hygienists?
Other Care Providers
Physicians?
Can you provide a list of employees hired within the last year?
Does your company provide New Employee Safety Orientation training?
Does your company hold safety meetings?
Are these meetings documented?
How often are these meetings? Check all that apply
Does your company have an accident reporting and investigation procedure?
Employee Notification:
How are employees notified of employee accidents and near misses?
What methods are used to notifiy or follow up with employees
How soon after an event do employees receive this notification?
Inspections and Audits
Do you conduct regular jobsite safety and health inspections?
Do you conduct audits for written safety and health training programs?
Do you conduct environmental inspections and audits?
Are audit results and upgrades to programs documented?
Do you conduct environmental compliance inspections on your job sites?
Equipment Inspections
Is this section applicable?
Do you conduct inspections on operating equipment (for example, cranes and forklifts)
Do you maintain operating equipment as required by safety regulations?
Do you maintian appropriate inspection and maintenance records for equipment?
Drug and Alcohol Program
Does your company have a written anti-alcohol/drug program?
Upload anti-alcohol/drug program
Does your drug and alcohol program include the following tests:
Pre-Employment?
Reasonable Suspicion Cause?
Post-Accident?
Random?
Is safety used as a performance criteria for evaluating:
Foremen?
Supervisors?
Management?
Employee Safety and Health Training
Does your company provide safety and health training?
Do your training records include the following information:
Employee indentification?
Date of training?
Name of trainer/instructor?
Method used to verify understanding?
