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Contractor Health and Safety Questionnaire

This document is a contractor safety and health questionnaire that asks for information about a contractor's safety performance, citations, safety program, safety activities, training program, reporting, and personnel. It requests documentation like OSHA forms, the company's safety plan, and training materials. It collects details on injury statistics, safety inspections, meetings, hazard assessments, and incident reporting. The contractor must sign to verify the accuracy of the information provided.

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Mart oro al
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95 views3 pages

Contractor Health and Safety Questionnaire

This document is a contractor safety and health questionnaire that asks for information about a contractor's safety performance, citations, safety program, safety activities, training program, reporting, and personnel. It requests documentation like OSHA forms, the company's safety plan, and training materials. It collects details on injury statistics, safety inspections, meetings, hazard assessments, and incident reporting. The contractor must sign to verify the accuracy of the information provided.

Uploaded by

Mart oro al
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Contractor Safety and Health Questionnaire

Date: ___________
Contractor Name: ______________________________________________

Safety Performance
Injury and Illness Statistics
Provide copies of your OSHA 300A Annual Summary forms for the previous 3 years, even
if there are no recorded injuries or illnesses.

Workers’ Compensation Experience Modification Rate (EMR)


Industry Code: _______________________
Industry Classification: _______________________
Current EMR: ____________

Citations
Has your company been cited or charged with one or more violations by a safety and health
regulatory agency in the past 3 years? YES / NO If yes, provide details on a separate sheet.

Safety Program
Do you have a written safety and health plan, program, or manual? YES / NO If
yes, provide a copy of your most recent version with this questionnaire.

Do you have supplemental safety and health information, such as a safety pocket guide,
guidance documents, or a safety Web page? YES / NO
If yes, provide copies of supplemental information and/or website URL with this questionnaire.

Safety Activities
Do you conduct safety inspections of your worksites? YES / NO
If yes, specify the frequency (daily, weekly, biweekly, other)? _____________________

Do you conduct safety meetings for your employees? YES / NO


If yes, specify how often (daily, weekly, other)? _________________________

Do you hold site meetings where safety and health issues are considered by managers and/or
site supervisors? YES / NO
If yes, specify how often (daily, weekly, other)? ________________________

Do you have a formal process for conducting hazard assessments? YES /


NO If yes, is the process documented and available for review? YES / NO

Do you prepare and implement site-specific safety and health plans? YES / NO
Contractor Safety and Health Questionnaire (cont’d)

Training Program
Do you provide safety and health training to your employees? YES / NO
If yes, provide the name of your trainer or training service provider.

Do you have a written training program? YES / NO


If yes, provide a copy of the relevant sections of your program that relate to the services you will
provide under the contract.

Reporting
Are incident and/or accident reports routinely documented? YES / NO

Who receives the reports?

What information is recorded in your incident/accident reports? (Check all that apply.)
( ) Fatality
( ) Injury
( ) Property damage
( ) Fire
( ) Security breach
( ) Near-miss incident
( ) Other (specify):

Personnel
Do you have a specific person or job function responsible for safety on your projects or
worksites? YES / NO
If no, who has overall responsibility and accountability for safety on your projects?

List the safety and health professionals and/or designees in the organization.
Name Position/Title Designation

The information contained in this questionnaire is an accurate description of the


organization’s occupational safety and health program.
Signature: __________________________________________

Print Name: _________________________________________

Job Title: ___________________________________________

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