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Contractors
Contractor Prequalification Form
Contractors
Contractors
Pre-Qualification Form
Note: Completion of the Contractor Pre-qualification does not guarantee work at Lambton College.
Company Identification
Company Name:
*
Mailing Address:
*
Telephone:
*
Fax:
*
Email:
*
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:
How many years has your organization been in business under your present name?
5. Parent Company Information:
Parent Name:
City:
Province / State:
Postal / Zip Code:
Subsidiaries:
6. Under Current Management Since (Date):
7. Insurance Contact Information:
*
Title:
*
Telephone:
*
Fax:
*
8. Insurance Carrier(s):
*
Name:
*
Type of Coverage:
*
Telephone:
*
Attach Certificate:
*
Organization
9. Describe nature of work your company specializes in:
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
Attach H&S Program: