Subcontractor Health & Safety Form

Subcontractor Pre-Qualification Form

Pat Munger Construction Company, Inc. requires all new Subcontractors to be pre-qualified before contracting with them to work on a Munger project. If you wish to be considered to be put on our bid list, please complete the Subcontractor Pre-Qualification Form below

To Our Valued Subcontractor, Please note the following Subcontractor Health & Safety Pre-Qualification Form policy revision will be effective immediately. Pat Munger Construction Company, Inc.’s (PMCCI) Subcontractor Health & Safety Pre-Qualification Form is required to be updated every five (5) Years. Under the new policy revision it will be the subcontractor’s obligation to submit a revised Subcontractor Health & Safety Pre-Qualification Form immediately following any Workers Compensation Insurance Experience Modification Rate (EMR) increase equal to or above 1.00 or immediately following any OSHA citation(s) that occurs within the five year eligibility period. Failure to submit such information may render you ineligible to be awarded a project. Certain clients of Munger Construction require any tier subcontractor to retain an EMR rate of less than 1.00, and not have any frequent or severe OSHA violations. It is Munger Construction’s responsibility to the client to enforce these requirements. Thank you for your cooperation in this matter. If you have any questions on this policy please feel free to contact Donna Turbert (dturbert@mungerconstruction.com, 203-483-3545) directly. Please sign and date below indicating that you have read and agree to the above Policy and return this page with the completed Pre-Qualification Form.

Date

Name

First Last

Signature

PMCCI Corporate Health and Safety Program - "Safety Selection of Subcontractors"

Purpose:

To ensure Subcontractor responsibility for complying with safety standards imposed by PMCCI for all contracts with PMCCI expected to last in excess of one work day.

In pursuing continual improvement in Health & Safety Management, Pat Munger Construction Company, Inc. (PMCCI) requires a certain standard of Health & Safety Management from Subcontractors providing services to us. The Subcontractor will provide evidence of achieving a respectable standard of Occupational Health and Safety Management by providing PMCCI with a completed copy of this Subcontractor Pre Qualification Form and Subcontractor Obligation Form, along with a recent revision of a written Company Health and Safety Program.

This is the minimum standard of Occupational Health & Safety Management that PMCCI will accept.

*Please Note:

If your company currently does not have a written Health and Safety Management Program please submit a completed copy of this packet with a letter of intent that describes your current safety management system, how you plan to ensure worker and jobsite safety while participating in a PMCCI Project, and your future plans for developing a Corporate Health and Safety Plan.

Upload a completed copy of this packet

Max. file size: 50 MB.

Pat Munger Construction Company, Inc. is always concerned with the safety of its project sites, customers, employees, visitors, and for the general public. In order to promote personal safety the Pat Munger Construction Company, Inc. expects its subcontractors to maintain a better than average safety record and to submit the following information regarding their Safety Record, Program, and Company Policies before awarding a contract. This Pre-Qualification Form must be updated and resubmitted annually.

Company Name

Address

Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Construction Specialties

Average Number of Employees

1) Who is responsible for managing health and safety for your company?

Name

Title

2) Does your company have a written Health and Safety Program?

Yes

No

4) Has your company had any OSHA recordable injuries/illnesses in the past 12 months?

Yes

No

If yes, please provide brief details. (Also attach copies of your firm's OSHA Form 300A from the previous three (3) years).

OSHA forms 300a

Max. file size: 50 MB.

5) Please provide your company's Workers Compensation Insurance Experience Modification Rate (EMR) from your last three rating periods:

Current EMR:

One Year Ago:

Two Years Ago:

6) Has your company received any OSHA Citations within the past five years?

Yes

No

If yes, please explain nature of citation:

7) Do you have a safety training program and have available training records for new and existing staff:

Yes

No

8) Have all your employees received OSHA 10 or 30 Hour Outreach Training?

Yes

No

If so, have your employees received the training within the past five years?

Yes

No

(If you cannot provide proof of course completion within the past five (5) years your company may not be eligible to work on any prevailing wage project of $100,000 or more).

9) When is Job Task related training performed? (Check all that apply)

Untitled

New Employee Orientation

New Work Site Orientation

Annually

Project Task Specific

After Accident/Incident

As Needed

10) Please provide a brief list of Job Task Training topics covered:

Job Task Training topics covered:

11) is the machinery or equipment you intend to use designed, set-up, and maintained for safe employee use?

Yes

No

12) Does your company have frequent inspection procedures for all machinery and equipment?

Yes

No

Please Describe:

13) Do you have an established Health and Safety Committee that meets at least quarterly?

13) Do you have an established Health and Safety Committee that meets at last quarterly?

Yes

No

Do you hold safety meetings with employees on a regular basis?

Yes

No

Please Describe:

Before commencing any work in any place of work controlled by the Pat Munger Construction Company Inc., Subcontractors must ensure that all of their employees and any Sub-Subcontractors are fully aware of:

Emergency procedures to be followed in the event of an emergency
Safety rules and procedures
Hazards which have been identified

The Subcontractor Shall (note that this list is not all-inclusive):

Ensure that his or her employees and Sub-Subcontractors comply with the Subcontractor's Health and Safety Program as well as OSHA standards, and all safety standards established during the progress of the work by Pat Munger Construction.
Prevent accidents to their employees by performing their work safely and collectively, utilizing job planning, worksite analysis, hazard control, and employee safety involvement and training.
Report any hazardous conditions and mitigate "areas of concern" before an illness, injury, near miss or other incident is realized.
Appoint a "competent or qualified persons" (via OSHA standard) who are authorized and able to recognize and anticipate hazards. The qualifications of all competent and qualified individuals shall be made available to Pat Munger Construction Company upon request. Such persons shall have authority to take prompt corrective action to abate hazards. Such persons will also have the authority to alter, modify or stop work plans in the process of hazard review or abatement.
Advise their employees of the potential fire, explosion, or toxic release hazards related to their job, and the process.
Document Safety Training of its employees and Sub-Subcontractors.
Submit SDSs for any hazardous materials stored on site or used to perform their work, and inform their employees and any other significant contractors the hazards of these materials. Subcontractors are responsible for maintaining SDS's on site for all hazardous materials.
Inform Pat Munger Construction employees and any other workers of specific potential; hazards created by the Subcontractor.
Subcontractor shall notify Pat Munger Construction Company within one (1) hour of any incident involving injury (or near miss of injury/damage) to any person or property. In addition, each Subcontractor shall investigate and document all such incidents. Findings shall be documented in an incident report and submitted to Contractor within 24 hours of the incident. All such incident reports will contain, but not be limited to;
- Date of event
- Chain of events leading to incident
- Impacted or injured parties (i.e., name, craft, position)
- Impacted property and estimated damage costs
- Primary and contributing causes of incident
- Immediate corrective measures taken
- Lessons learned for wider application by Subcontractor or Contractor
- Other items as requested by the Contractor
- Witness Statements
Maintain a Designated Safety Representative on site at all times when the Subcontractors' employees are working. Erect and maintain appropriate barricading, sign-posting, and fire watches.
Provide its employees with medical care and first-aid treatment. Inform their employees as to the location of the first-aid and medical services.
Have on file the phone numbers of the nearest hospital, ambulance service, and fire department.
Provide its employees with appropriate firefighting equipment for fire watches.
Provide supervisors and employees who are competent and adequately trained, including training in all health and safety aspects of the work involved in the contract.
Provide all tools and equipment for the work, including personal protective equipment, and ensure the equipment is in proper working order and employees are instructed in its proper use.
Maintain good housekeeping in the workplace; cleaning shall be performed daily.
Follow specific instructions provided by Pat Munger Construction should emergency alarms be activated, and ensure their employees know these specific instructions.
Inform the Designated Safety Representative of all potential hazards they may introduce to the job site.
Train all employees on all safety and health hazards and provisions applicable to the type of work being done.
Ensure that all hand tools and power tools are inspected, have proper guarding, are in safe working order, and employees are trained in their proper use.
Ensure that all extension cords are of a heavy-duty, 3-wire type, and are in good condition.
Ensure only Type I and Type II ladders are used and are inspected before use, and shall be removed from service if broken, damaged or unsafe.
Ensure inspections and maintenance of all ariel platform lifts and booms meet OSHA and ANSI standards for safe operation, and that all operators have received appropriate training.
Ensure scaffolding is erected in accordance with the CFR 1926.451 subpart L. Standard guardrails for fall protection and ladders for safe access shall be used.
Shore, slope, bench, and protect any open trench or excavation.
Ensure inspections and maintenance of all industrial powered equipment such as forklifts, tele-handlers, and all excavation equipment meet OSHA and ANSI standards for safe operating, and that all operators have received appropriate training.
Utilize lock out /tag out methods to control release of hazardous energy.
Subcontractor will utilize a 100% 6-foot fall protection policy and program. Each person on a walking or working surface with an unprotected side or edge which is 6 feet or more above the next lower level shall be protected from falls using the Hierarchy of Controls (elimination, substitution, engineering, administrative, and personal protective equipment). As such, personal fall arrest systems (PFAS) should be considered as the last option. All personnel and all tiers will comply with this requirement, including Roofers, Ironworkers, Erectors, and Connectors, regardless of any exemptions that might otherwise be available under OSHA, trade agreement or other applicable law.
The following exceptions to the 100% 6 foot fall requirement may exist, depending on site specific requirements:
- Proper use of a step ladder (up to 12 feet) on a stable and level foundation and away from wall/window openings, mezzanines or other fall hazards.
- Proper use of an approved and inspected extension ladder (up to 24 feet) for movement between levels (not as a working platform).
- Other extraordinary circumstances only if: (i) Subcontractor's competent person determines that neither engineering controls nor a PFAS would be feasible; (ii) Contractor provides prior approval in writing; and (iii) the method of proceeding complies with all applicable laws.
Subcontractor shall provide adequate safety measures and controls to address potential occupational exposures such as gases, fumes, silica, dusts, chemicals, noise, and confined spaces.
Per OSHA 1926.1153, each subcontractor covered by the silica standard shall establish and implement a written silica exposure control program that identifies tasks that involve potential exposure and methods the company will use to protect employees. Procedures and protocols may include restricting access to work areas where high exposures may occur, designation of a competent person to implement the plan, restricting housekeeping practices that expose employees to silica where feasible alternatives are available, and use of appropriate tools and work practices to minimize the potential for exposure. The plan must be reviewed prior to the start of work.
Provide proper Spark and /or Arc shielding and Fire watches for cutting / welding applications. Obtain Operators credentials and documentation of inspections for any on-site crane.
A defined "flow down" strategy will be developed by subcontractor to ensure program adherence and consistency by all lower tier subcontractors.
PERSONAL PROTECTIVE EQUIPMENT
Each subcontractor is solely responsible to supply their employees with the required Personal Protective Equipment.

Eye and Face Protection
- All employees shall wear safety glasses 100% of the time while on the construction site. Minimum eye protection shall include approved safety glasses with side-shields which meet the standards specified in ANSI/ISEA Z-87.1-2015 (this shall also include prescription eyewear). • Additional eye and face protection in combination shall be worn when:
  - Welding, burning or cutting with torches;
  - Using abrasive wheels, portable grinders;
  - Drilling, cutting or chipping at or above shoulder level;
  - Chipping concrete, stone or metal;
  - Working with any materials subject to scaling, flaking or chipping;
  - Drilling or working under dusty conditions;
  - Using explosive actuated fastening or nailing tools at or above shoulder level;
  - Working with compressed air or pneumatic tools;
  - Using masonry saw;
  - Additional PPE as determined by the project or task-specific requirements, Daily Huddle and/or Job Hazard Analysis.
Head Protection
- All employees, vendors, delivery personnel and other visitors to the project shall wear hard hats that meet ANSI/ISEA Z-89.1-2014, 100% of the time while on the construction site (including while wearing face shields, welding helmets, etc.).
Foot Protection
- All personnel on the construction site shall wear hard-soled work shoes. No one is permitted to wear sneakers, tennis shoes or athletic shoes of any type, sandals, high heels or open toed shoes on the construction site. Additional foot protection may be required depending on work activity as dictated by subcontractor's JHA.
Respiratory Protection

If respiratory protection is required to protect employees from exposures to airborne contaminants, subcontractors must adhere to the following:
- Compliance with the applicable standards (respiratory, specific contaminants, etc.);
- Annual medical clearance for employee;
- Annual fit-testing for employee;
- Training for employee on respirator;
- Written respiratory protection program;
Hearing Protection
- Hearing protection is required in accordance with OSHA standards.
High Visibility
- High visibility shirt/vest
After conclusion of the contract work, inspect to ensure that all hazards related to contracted work no longer exist, and clean all work areas and dispose of any discarded materials in a proper, legal manner.

________________________________________________________________________

The items on the Pat Munger Construction Company, Inc. Subcontractor Health and Safety Obligation Form have been read, discussed, and understood

Company

Date

Signature

Subcontractor Health & Safety Form

Subcontractor Pre-Qualification Form

Subcontractor Pre-Qualification Form

PMCCI Corporate Health and Safety Program - "Safety Selection of Subcontractors"

1) Who is responsible for managing health and safety for your company?

2) Does your company have a written Health and Safety Program?

3) Does your Program or Company Policies cover the following:

4) Has your company had any OSHA recordable injuries/illnesses in the past 12 months?

5) Please provide your company's Workers Compensation Insurance Experience Modification Rate (EMR) from your last three rating periods:

6) Has your company received any OSHA Citations within the past five years?

7) Do you have a safety training program and have available training records for new and existing staff:

8) Have all your employees received OSHA 10 or 30 Hour Outreach Training?

9) When is Job Task related training performed? (Check all that apply)

10) Please provide a brief list of Job Task Training topics covered:

11) is the machinery or equipment you intend to use designed, set-up, and maintained for safe employee use?

12) Does your company have frequent inspection procedures for all machinery and equipment?

13) Do you have an established Health and Safety Committee that meets at least quarterly?

YOU HAVE A VISION.
WE HAVE A PROVEN PROCESS TO GET YOU THERE.

Subcontractor Health & Safety Form

Subcontractor Pre-Qualification Form

Subcontractor Pre-Qualification Form

PMCCI Corporate Health and Safety Program - "Safety Selection of Subcontractors"

1) Who is responsible for managing health and safety for your company?

2) Does your company have a written Health and Safety Program?

3) Does your Program or Company Policies cover the following:

4) Has your company had any OSHA recordable injuries/illnesses in the past 12 months?

5) Please provide your company's Workers Compensation Insurance Experience Modification Rate (EMR) from your last three rating periods:

6) Has your company received any OSHA Citations within the past five years?

7) Do you have a safety training program and have available training records for new and existing staff:

8) Have all your employees received OSHA 10 or 30 Hour Outreach Training?

9) When is Job Task related training performed? (Check all that apply)

10) Please provide a brief list of Job Task Training topics covered:

11) is the machinery or equipment you intend to use designed, set-up, and maintained for safe employee use?

12) Does your company have frequent inspection procedures for all machinery and equipment?

13) Do you have an established Health and Safety Committee that meets at least quarterly?

YOU HAVE A VISION. WE HAVE A PROVEN PROCESS TO GET YOU THERE.

YOU HAVE A VISION.
WE HAVE A PROVEN PROCESS TO GET YOU THERE.