About UsServicesPeopleNewsContact Us Contractor Registration
 
  west construction management
  west construction management
 
     

Contractor Prequalification

Contractor or
Sub-Contractor
Address
City
State
Zip
Telephone
Email
Fax:
Completed By:
Title:
   
Company's Safety Manager, Director, or Representative
Name
Telephone
Fax
   
Company's Current Workers' Compensation Carrier
Carrier Name
Policy Number
   
Company's Safety Manual or equivilant Work Rules
Please check as appropriate Safety Manual
Work Rules
Enclosed
Underway
   
Copy of OSHA 300A Logs (Summary of Occupational Injuries and Illnesses) for current and preceding two years
Please check as appropriate Enclosed
Underway
   
Copy of OSHA citations received for current and preceding two years.
Please check as appropriate None
Enclosed
Underway
   
Provide listing of those employees anticipated to participate in the work, including knowledge/skill levels (as appropriate).
Please check as appropriate Enclosed
Underway
   
Please provide safety training records for all participating employees (as appropriate)
Please check as appropriate Enclosed
Underway
   
Please provide your company's Experience Modification Rate (EMR) for the past three years:
Year/Rate
Year/Rate
Year/Rate
   
Please refer to your company's OSHA 300A Log to provide the following for last year:
Number of Fatalities
Number of lost workday cases:
Number of restricted workday cases:
Number of recordable cases
(medical attentional only)
   
How many hours, for each of the last three years, were worked by your employees (do not include any non-work time, even though paid)?
Year/Hours
Year/Hours
Year/Hours
   
Please check your company's type of work
Please check as appropriate Heavy Construction
Non-Residential Building
Plumbing/Heating/Air Conditioning
Other
If Other, Describe:
   
Does your company have a written safety program?
Please check as appropriate Yes
No
   
If yes, does the safety program include instruction on the following?
Please check as appropriate

Eye and face protection (OSHA 29 CFR 1910.133)
Respiratory protection (OSHA 29 CFR 1910.134)
Head protection (OSHA 29 CFR 1910.135)
Foot protection (OSHA 29 CFR 1910.136)
Hand protection (OSHA 29 CFR 1910.138)
Occupational noise exposure (OSHA 29 CFR 1910.95)
Guarding floor and wall openings and holes (OSHA 29 CFR 1910.23)
Safety requirements for scaffolding (OSHA 29 CFR 1910.28)
Powered industrial trucks (OSHA 29 CFR 1910.178)
Medical services and first aid (OSHA 29 CFR 1910.151)
Portable fire extinguishers (OSHA 29 CFR 1910.157)
Employee emergency plans and fire prevention plans (OSHA 29 CFR 1910.38)
Hazard communication (OSHA 29 CFR 1910.1200)
Permit-required confined spaces (OSHA 29 CFR 1910.146)
The control of hazardous energy (lockout/tagout) (OSHA 29 CFR 1910.147)
Process safety management of highly hazardous chemicals (OSHA 29 CFR 1910.147)
Hazardous waste operations and emergency response (OSHA 29 CFR 1910.119)
Housekeeping (OSHA 29 CFR Subpart D, Walking-Working Surfaces, 1910.22)
Powered Platforms, Manlifts, and Vehicle-Mounted Work Platforms, including Personal Fall Arrest Systems (OSHA 29 CFR Subpart F, 1926 subpart M)
Hand and Portable Powered Tools and other Hand-Held Equipment (OSHA 29 CFR 1910 Subpart P)
Welding, Cutting, and Brazing (OSHA 29 CFR 1910 Subpart Q)
Electrical (OSHA 29 CFR 1910 Subpart S)
Excavations (OSHA 29 CFR 1926 Subpart P)

   
Does your company provide orientation training for employees?
Please check as appropriate Yes
No
   
Does your company provide periodic refresher/retraining for employees?
Please check as appropriate Yes
No
   
Does your company hold site safety meetings?
Please check as appropriate Yes
No
If Yes, How Often? Weekly
Biweekly
Monthly
Less often,, as needed
   
Does your company conduct project safety inspections?
Please check as appropriate Yes
No
If Yes, who conducts these inspections?
How often?
   
Does your company require that all incidents/accidents be promptly reported and investigated to determine root cause and corrective action?
Please check as appropriate Yes
No
   
Does your company include safety and health criteria as a part of periodic employee performance evaluations?
Please check as appropriate Yes
No
   
Is your company or are your employees licensed, registered or certified in any way?
Please check as appropriate Yes
No
   
Is your company bonded? If yes, please email a copy of certificates showing bond coverage to: info@west-cm.com
Please check as appropriate Yes
No
   
Does your company hold the following insurance converages?
Comprehensive General Libaility and Automobile Bodily Injury:
Please check as appropriate $200,000 per person - Bodily Injury
$500,000 per person - Bodily Injury
$250,000 per person - Property Damage
Workers Compensation
Please check as appropriate $1,000,000
Note: Please email verification of the required insurance information to: info@west-cm.com
   
 
   

 

West Construction Management
s