Contractors

Company Identification

Form of Business: *

Sole Owner
Partnership
Corporation

Officers:

Table with fields to enter company officer's name and how many years they've been with the company.

Position	Name	Years With Company
President/C.E.O.:
Vice-President:
Treasurer:
Health & Safety Supervisor:

5. Parent Company Information:

Parent Name:

City:

Province / State:

Postal / Zip Code:

Subsidiaries:

7. Insurance Contact Information: *

Title: *

Telephone: *

Fax: *

8. Insurance Carrier(s): *

Name: *	Type of Coverage: *	Telephone: *

Organization

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

Yes
No

Company Work History

11. Jobs completed in the past 3 years that may be contacted for reference: (provide at least 3)

Customer Name:

Address & Telephone:

Type of Work:

Contract Value:

Customer Contact:

Customer Fax #:

 

Customer Name:

Address & Telephone:

Type of Work:

Contract Value:

Customer Contact:

Customer Fax #:

 

Customer Name:

Address & Telephone:

Type of Work:

Contract Value:

Customer Contact:

Customer Fax #:

 

Customer Name:

Address & Telephone:

Type of Work:

Contract Value:

Customer Contact:

Customer Fax #:

Are there any judgements, claims or suits pending or outstanding against your company? *

Yes
No

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

Yes
No

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

Yes
No

If yes, please name:

Safety & Health Performance

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

Yes
No

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.) *

Yes
No

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?

Yes
No

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

Yes
No

If yes, what was your final score:

Safety & Health Program and Procedures

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

Yes
No

Do you have a written Safety and Health Program?

Yes
No

Does the program address the following key elements?

a) Management commitment and expectations

Yes
No

b) Employee participation

Yes
No

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

Yes
No

d) Resources for meeting safety and health requirements

Yes
No

e) Periodic safety and health performance appraisals for employees

Yes
No

f) Hazard recognition and control

Yes
No

20. Does the program include work practices and procedures such as:

a) Equipment Lockout and Tag-out (LOTO)

Yes
No

b) Confined Space Entry

Yes
No

c) Fall Protection

Yes
No

d) Personal Protective Equipment

Yes
No

e) Portable Electrical / Power Tools

Yes
No

f) Vehicle Safety

Yes
No

g) Compressed Gas Cylinders

Yes
No

h) Electrical Equipment Grounding Assurance

Yes
No

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

Yes
No

j) Housekeeping

Yes
No

k) Accident / Incident Reporting

Yes
No

l) Unsafe Condition Reporting

Yes
No

m) Emergency Preparedness, including Evacuation Plan

Yes
No

n) Waste Disposal

Yes
No

o) Respiratory Protection

Yes
No

p) Designated Substance Management

Yes
No

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?

Yes
No

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.)

Yes
No

Attach Plan:

23. Medical:

a) Do you have personnel certified in Standard First Aid/CPR

Yes
No

b) Do you have an emergency plan in place?

Yes
No

c) Are First Aid Kits provided?

Yes
No

24. Personal Protective Equipment (PPE):

a) Is application PPE provided for employees?

Yes
No

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

Yes
No

c) Are employees trained in PPE use?

Yes
No

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

Yes
No

26. Equipment & Manuals:

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

Yes
No

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

Yes
No

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

Yes
No

d) Are records available upon request?

Yes
No

27. Subcontractors:

a) Do you use safety and health performance criteria in selection of subcontractors?

Yes
No

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

Yes
No

c) Do you include your subcontractors in:

- Safety and Health Orientation

Yes
No

- Safety and Health Meetings

Yes
No

- Inspections

Yes
No

- Audits

Yes
No

28. Safety & Health Training

a) Do you know the regulatory safety and health training requirements for your employees?

Yes
No

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

Yes
No

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

Yes
No

29. Job Skills

a) Have employees been trained in appropriate job skills?

Yes
No

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

Yes
No

c) Are certificates available upon request?

Yes
No

30. Training Records

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

Yes
No

b) Are records available upon request?

Yes
No