APPENDIX A AURA SAFETY AND HEALTH QUESTIONNAIRE FOR BIDDERS

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1 APPENDIX A AURA SAFETY AND HEALTH QUESTIONNAIRE FOR BIDDERS Evaluation Criteria for Bidder Selection All bidders are required to complete the AURA Safety and Health Questionnaire for Bidders that will be used to evaluate potential contractors. All general Contractors shall require subcontractors to comply with the Safety and Health Specification (SPEC _0031). The AURA Safety and Health Questionnaire for Bidders will be provided to bidders wishing to be Contractors during the proposal process and shall be completed and submitted to AURA with the proposal documents. The questionnaire will be used by AURA to assess bidder s safety performance and programs and will be used during the selection process. Company name: Street Address: Fax: Mailing Address: Contact Person: List the officers of the Company (include years with Company): President: Vice President: Treasurer: How many years has the Company been in business under the present firm name? Is there a parent Company? Name: Tax ID#: City: State: Zip Code: Subsidiaries: Who is the Company contact for insurance information? Name: Title: Fax:

2 List name, type of coverage, and telephone number of the Company s insurance carrier(s): Is the Company self-insured for worker s compensation insurance? Who is the Company contact for requesting bids? Name: Title: Fax: This form was completed by: Name: Title: Fax: Type of Business of the Company: Sole Owner! Partnership! Corporation! What is the Company SIC or NAICS (North American Industry Classification System) Code? Describe the services performed by the Company:! Construction! Construction design! Original equipment manufacturer and installer! Project maintenance! Maintenance! Original equipment manufacturer and maintenance! Service work (e.g., janitorial, clerical, etc.)! Manpower and resource! Other List other types of work within the services of the Company that are subcontracted: Does the Company normally employ?! Union Personnel! Non-Union Personnel! Leased Personnel

3 If union, list trades/locals: List Company paid benefits provided to your employees: Annual US dollar volume for the past three years: $, 2007 $, 2008 $, 2009 Largest job during the last three years: $ Bonding Capacity: What is the Company s (Dun & Bradstreet) D&B Financial Rating: Annual Sales $ Net Worth: $ Major jobs in progress (list customer/location, type of work, size $M, customer contact, and telephone): Major jobs completed in the past three years (list customer/location, type of work, size $M, customer contact, and telephone): Are there any judgments, claims, or suits pending or outstanding against the Company? If yes, please note details. Are there now or has the Company been involved in any bankruptcy or reorganization proceedings? If yes, please note details:

4 Company s workers compensation experience modification rate (EMR) data: EMR is:! Interstate rate! Intrastate rate! Monopolistic State rate! Dual rate EMR for three last years: $, 2007 $, 2008 $, 2009 State of Origin: EMR Anniversary Date: Company employee hours worked last three years (excluding subcontractors), 2007, 2008, 2009 Provide the number of injuries and illnesses (excluding subcontractors) and the OSHA Total Recordable Injury/Illness Rate by using OSHA 300 Forms from the past three years: 2007 Number: Rate: 2008 Number: Rate: 2009 Number: Rate: List the number of Injuries/Illnesses that resulted in fatalities and provide specific details on those accidents: Notes: (1) Total OSHA Recordable Injury/Illness Rate = Total Recordable Injury/Illness cases x 200,000 divided by Total Employee Hours. (2) Data should be the best available data applicable to the work in this region or area. (3) If your company is not required to maintain OSHA 300 forms, please provide information from your Worker s Compensation insurance carrier itemizing all claims for the last three years. Has the Company received any regulatory (EPA, OSHA, etc.) citations in the last three years? If yes, please provide a brief description of each:

5 Who is the Company s highest ranking safety and health professional? Name: Title: Fax: Does the Company have a: Full time Safety/Health Director Full time Site Safety/Health Supervisor Full Time Job Safety/Health Coordinator Have all employees been trained in appropriate job skills? Are employees job skills certified where required by regulatory or industry consensus standards? Is there a Company safety and health policy? Does the Company have a written safety and health plan or program? Does the plan or program include work practices and procedures such as? Equipment Lockout and Tagout (LOTO) Confined Space Entry Injury & Illness Recording Fall Protection Personal Protective Equipment Portable Electrical/Power Tools Vehicle Safety Compressed Gas Cylinders Electrical Equipment Grounding Assurance Powered Industrial Vehicles (Cranes, Forklifts, etc.) Housekeeping Accident/Incident Reporting Unsafe Condition Reporting Emergency Preparedness, including evacuation plan Waste Disposal Hearing Conservation Respiratory Protection Hazard Communication

6 Does the Company have a corrective action process for addressing individual safety and health performance deficiencies? Does the Company have an alcohol and substance abuse program? If yes, does it include the following? Post Accident Testing Pre-placement Testing Random Testing Testing for Cause DOT Testing Do Company employees read, write, and understand English such that they can perform their job tasks safely without an interpreter? If no, provide a description of the plan to assure that they can safely perform their jobs. Does the Company conduct employee medical examinations for? Pre-placement/ Job Capability Hearing Function (Audiograms) Pulmonary Respiratory Are there employees trained to perform first aid and CPR? Is applicable Personal Protection Equipment (PPE) provided for employees? Is there a program to assure that PPE is inspected and maintained? Where applicable, have employees been trained, fit tested, and medically approved for PPE use? Yes [ ] No [ ] Does the Company conduct safety and health inspections? Does the Company conduct inspections on operating equipment (e.g., cranes, forklifts, etc) in compliance with regulatory requirements? Does the Company maintain operating equipment in compliance with regulatory requirements? Does the Company maintain the applicable inspection and maintenance certification records for operating equipment?

7 Does the Company conduct safety and health program audits? Are corrections of deficiencies documented? Does the Company use safety and health performance criteria in selection of subcontractors? Is there an evaluation of the ability of subcontractors to comply with applicable health and safety requirements as part of the selection process? Do you have a Safety and Health Orientation Program for new hires? Does the program provide instruction on the following? Safe Work Practices Safety Supervision Toolbox Meetings Emergency Procedures First Aid Procedures Accident/Incident Reporting Fire Protection and Prevention Safety Intervention Hazard Communication How long is the orientation program in hours? Does the Company have safety and health training program for supervisors? Are there site safety and health meetings for? Supervisors Employees Subcontractors Are the safety and health meetings documented?

8 INFORMATION SUBMITTAL Please provide copies of the following applicable items with this completed form: (Note: Minimum submittal requirements pre-marked.) " EMR documentation from your insurance carrier " Insurance Certificate(s)! OSHA 200/300 Logs (Past 3 Years)! Safety and Health Plan or Program! Substance Abuse Program! Safety and Health Inspection Form! Safety and Health Audit Procedure or Form! Safety and Health Orientation (Outline)! Example of Employee Safety and Health Training Records! Safety and Health Training for Supervisors (Outline)! Organization Chart! List of your major equipment (e.g. cranes, forklifts, etc.) Contractor is: FORM EVALUATION! AURA USE ONLY! DO NOT FILL OUT! AURA USE ONLY! Acceptable for Approved Contractor List! Conditionally acceptable for Approved Contractor List Conditions: Reviewer: Date:

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