Contractor Prequalification Form

Note: Completion of the Contractor Pre-qualification does not guarantee work at Lambton College.

Company Identification

Form of Business: *

Table with fields to enter company officer's name and how many years they've been with the company.
Position Name Years With Company
Health & Safety Supervisor:
5. Parent Company Information:
7. Insurance Contact Information: *
8. Insurance Carrier(s): *
Name: * Type of Coverage: * Telephone: *


10. Are any of the above services you normally perform subcontracted to others? *

Company Work History

11. Jobs completed in the past 3 years that may be contacted for reference: (provide at least 3)
Are there any judgements, claims or suits pending or outstanding against your company? *

Have you received any (MOL, MOE, etc.) orders and/or prosecutions in the last 3 years? *

Do you have involvement in organizations such as Safe Work Associations? *

Safety & Health Performance

Can you provide proof of Workplace Safety and Insurance? (Certificate of Clearance) *

16. Is your company experience rated (CAD-7, NEER)? (If yes, attach CAD-7reports for the last 3 years and go to item 18. If no, complete item 17.) *

17. Has an employee of your company suffered a work related fatal accident or "critical injury" as defined by the Ontario Occupational Health & Safety Act?

18. Has your company ever been subjected to a Work-well Audit?

Safety & Health Program and Procedures

19. Do you have a written Health & Safety Policy?

Do you have a written Safety and Health Program?

Does the program address the following key elements?
a) Management commitment and expectations

b) Employee participation

c) Accountabilities & responsibilities for managers, supervisors, and employees

d) Resources for meeting safety and health requirements

e) Periodic safety and health performance appraisals for employees

f) Hazard recognition and control

20. Does the program include work practices and procedures such as:
a) Equipment Lockout and Tag-out (LOTO)

b) Confined Space Entry

c) Fall Protection

d) Personal Protective Equipment

e) Portable Electrical / Power Tools

f) Vehicle Safety

g) Compressed Gas Cylinders

h) Electrical Equipment Grounding Assurance

i) Powered Industrial Vehicles (Cranes, Forklifts, etc)

j) Housekeeping

k) Accident / Incident Reporting

l) Unsafe Condition Reporting

m) Emergency Preparedness, including Evacuation Plan

n) Waste Disposal

o) Respiratory Protection

p) Designated Substance Management

21. Do you have a policy for the termination of contracts of subcontractors who do not comply with the Occupational Health & Safety Act and Regulations and or Company Rules and Policies?

22. Do your employees read, write and understand English such that they can perform their job tasks safely without an interpreter? (if no, provide a description of your plan to assure that they can safely perform their jobs.)

23. Medical:
a) Do you have personnel certified in Standard First Aid/CPR

b) Do you have an emergency plan in place?

c) Are First Aid Kits provided?

24. Personal Protective Equipment (PPE):
a) Is application PPE provided for employees?

b) Do you have a program to assure that PPE is inspected and maintained?

c) Are employees trained in PPE use?

25. Do you have a corrective action process for addressing individual safety and health performance deficiencies?

26. Equipment & Manuals:
a) Do you conduct inspections on operating equipment (e.g. cranes, forklifts, etc) in compliance with regulatory requirements?

b) Do you maintain operating equipment in compliance with regulatory requirements?

c) Do you maintain the applicable inspection and maintenance certification records for operating equipment?

d) Are records available upon request?

27. Subcontractors:
a) Do you use safety and health performance criteria in selection of subcontractors?

b) Do your subcontractors have a written health and safety program?

c) Do you include your subcontractors in:
- Safety and Health Orientation

- Safety and Health Meetings

- Inspections

- Audits

28. Safety & Health Training
a) Do you know the regulatory safety and health training requirements for your employees?

b) Have your employees received the required safety and health training and retraining?

c) Do you have a specific safety and health training program for supervisors?

29. Job Skills
a) Have employees been trained in appropriate job skills?

b) Are employee job skills certified where required by regulation or industry standards?

c) Are certificates available upon request?

30. Training Records
a) Do you keep safety, health, and job skill training records for employees?

b) Are records available upon request?

Back to Top