Standard Pre-Qualification Form (PQF)

GENERAL INFORMATION
1. Company Name: Telephone: Fax:
Street Address: Mailing Address:

Web Site:

Contact Person: Email:

Telephone: Fax:

2. Officers Years With Company

President:

Vice President:

Treasurer:

3. How many years has your organization been in business under your present firm name?

4. Parent Company Name:

City: State: Zip:

Subsidiaries:

5. Under current management since:

6. Contact for Insurance Information:

Title: Telephone: Fax:

7. Insurance Carriers Type of coverage Telephone

8. Are you self insured for Worker's Compensation Insurance?

9. Contact for Requesting Bids: Title:

Telephone: Fax: Email:

10. PQF Completed By: Title: Date:

Telephone: Fax: Email:

ORGANIZATION
11. Form of Business Sole Owner Partnership Corporation Date and State of Incorporation:

12. Percent Minority / Female Owned: EEO Category:

13. A. Describe Services Performed

Construction Construction Design Original Equipment Manufacturer and Installer

Maintenance Specialty Maintenance Manpower and Resource

Original Equipment Manufacturer and Maintenance Service Work (e.g. Janitorial, Clerical, Etc.) Turnaround

Engineering Other

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13. B. Work Categories
Check the categories in which you are interested in bidding and in which you are qualified to perform work. Attach additional information clarifying your
capabilities and specialities.
(C) denotes work done by company employees (S) denotes work done by subcontractors
C S 1. Air Conditioning / Refrigeration C S 12. Instrumentation

Comfort Cooling / HVAC General

Process Refrigeration DCS Control Systems

C S 2. Buildings C S 13. Insulation

Remodeling General

New (steel, brick, block, other) Asbestos Abatement

C S 3. Cleaning C S 14. Linings/coatings for:

Industrial Metal

Janitorial Concrete

C S 4. Civil C S 15. Field Maintenance

Concrete General

Excavation/Grading Paving Hot Tap/line stops

- Asphalt Leak Sealing (online)

- Concrete Field Machining

5. Demolition/Dismantling Tank/Vessel Code

C S 6. Electrical Boiler Code

General Exchanger Retubing

High-voltage/High-line Rotating Equipment

Heat Tracing Valve

Cathodic Protection Cooling Tower

Grounding Systems High Alloy Welding (list type)

C S 7. Inspection & Testing Lead Lining

General NDT Glass Lining

Radiography Heat Treating

Infared Scanning Nonmetallic materials

Eddy Current Testing Pipe Fabrication

Acoustic Emission Mobile Equipment Repair

Column Scanning 16. New Construction

Civil/Soils 17. Painting

High Voltage Electrical 18. Refractory/Acid Brick

Electrical Ground Inspection 19. Rigging/Equipment Erection

Fiberglass Inspection C S 20. Consulting

C S Mechanical

8. Scaffolding Electrical

9. Scale Maintenance Chemical

10. Structural Steel Fab/Erection Metallurgical

11. Tanks - Field Erection Controls

Describe Additional Services Performed:

14. A. Do you normally employ Union Personnel? Non-Union Personnel? Leased Personnel?
If union, list trades/locals:

B. Average number of employees for last 3 years:

15. Annual Dollar Volume for the Past Three Years: Year: Year: Year:

$ $ $

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16. Largest Job During the Last 3 Years:

17. Your Firm's Desired Project Size Maximum: $ Minimum: $

18. a.D&B Financial Rating: 18 b. Annual Sales: 18.c. Net Worth:

18.d. DUNS #: Date: 18.e. Tax ID #:

19. Bank Line of Credit $: Bonding Capacity $

Bank Reference(s):

20. Major jobs in progress

Customer/Location Type of Work Size Customer Contact Telephone

21. Major jobs completed in the past three years

Customer/Location Type of Work Size Customer Contact Telephone

22. Are there any judgments, claims or suits pending or outstanding against your company? If yes, please attach details.

23. Are you now or have you ever been involved in any bankruptcy or reorganization proceedings? If yes, please attach details

SAFETY & HEALTH PERFORMANCE

24. Workers Compensation Experience Modification Rate (EMR) Data

a. EMR is: b. EMR for three last years

Interstate rate YEAR EMR

Intrastate rate

Monopolistic State rate

Dual Rate
c. State of Origin d. EMR Anniversary Date:

e. Standard Industrial Classification (SIC):

25. Injury and Illness Data:

a. Total company employee hours worked last three years (excluding subcontractors)

Hours / Year Year: Year: Year:

Field

Total

b. Provide data (excluding subcontractor) using your OSHA 200 and 300 Forms from the past three (3) years:
Notes:
(1) Data should be total company data unless specifically requested by client.
(2) Combine injuries and illnesses from 200 Form as reported on 300 Form
(3) If your company is not required to maintain OSHA 200/300 forms, please provide information from your Worker's Compensation insurance carrier itemizing all
claims for the last 3 years.

Year: Year: Year:

Fatalities No. Rate: No. Rate: No. Rate:

Rate = Number of Fatalities x 200,000 / Total Employee Hours
Lost workday case injuries and illnesses involving days away from work, or No. Rate: No. Rate: No. Rate:
days of restricted work activity, or both.
Rate = Total LW and restricted cases x 200,000 / Total Employee Hours
Lost workday case injuries and illnesses involving days away from work. No. Rate: No. Rate: No. Rate:
Rate = LW cases** x 200.000 / Total Employee Hours
Injuries and Illnesses involving medical treatment only. No. Rate: No. Rate: No. Rate:
Rate = Total Injuries and Illnesses involving medical treatment only x 200,
000 / Total Employee Hours
Total OSHA Recordable Injury and Illnesses Rate No. Rate: No. Rate: No. Rate:
Rate = Total Injuries and Illnesses x 200,000 / Total Employee Hours

26. Have you received any regulatory (EPA, OSHA, etc.), civil or criminal citations in the last three years?

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 SAFETY, HEALTH & ENVIRONMENTAL MANAGEMENT
27. Name of highest ranking safety/health professional in the company

Name: Title: Certifications:

Telephone: Fax:

This person reports to: Title:

28. Do you have or provide: a. Full time Safety/Health Director b. Full time Site Safety/Health Supervisor c. Full Time Job Safety/Health Coordinator
29. Do you have or provide: a. Safety/Health incentive program b. Company paid safety/health training

SAFETY, HEALTH & ENVIRONMENTAL PROGRAMS / PROCEDURES

30. a. Do you have a written S, H E Program?
b. Does the program address the following key elements?

1. Management commitment and expectations 2. Employee participation

3. Accountabilities and responsibilities for managers, supervisors, and employees 4. Resources for meeting safety, health environmental requirements.

5. Periodic safety and health performance appraisals for all employees 6. Safety, Health Environmental Recognition Program

7. Hazard recognition and control

c. Does the program satisfy your responsibility under the law for:

1. Ensuring your employees follow the safety rules

2. Advising owner of any unique hazards presented by the contractors work and of any hazards found by the contractor
31. Does the program include work practices and procedures such as

a. Equipment Lockout and Tagout (LOTO) b. Confined Space Entry

c. Injury and Illness Recording d. Fall Protection

e. Personal Protective Equipment f. Portable Electrical/Power Tools

g. Vehicle Safety h. Compressed Gas Cylinders

i. Electrical Equipment Grounding Assurance j.Powered Industrial Vehicles (Cranes, Forklifts, JLGs)

k. Housekeeping l. Accident/Incident Reporting

m. Unsafe Condition Reporting n. Emergency Preparedness, including evacuation plan

p. Back Injury Prevention q. Hazwoper Training

r. Heat Stress Prevention s. Scaffold Builing /Scaffold Use

t. General NDTand Radiography

32. Do you have written programs for the following:

a. Hearing Conservation b. Spill prevention and waste minimization c. Hazard Communuication

d. Program to support contractor requirements of the OSHA Process Safety Management of highly hazardous chemicals;Explosives-blasting agents standard (29 CFR 1910

e. Respiratory Protection
Where applicable, have employees been: Trained? Fit tested? Medically approved?

33. Do you have a substance abuse program?

If yes, does it include the following?

Pre-placement Testing Random Testing Testing for Cause DOT Testing Post Incident Testing

34. 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.

35. Medical

a. Do you conduct medical examinations for:

Pre-placement Preplacement Job Capability Hearing Function (Audiograms) Pulmonary Respiratory

b.Describe how you will provide first aid and other medical services for your employees while on-site and specify who will provide this service

c. Do you have personnel trained to perform first aid and CPR?

36. Do you hold site safety, health and environmental meetings for:

Field Supervisors Frequency: Employees Frequency:

New Hires Frequency: Subcontractors Frequency:

Are the safety, health and environmental meetings documented?

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37. Personal Protection Equipment (PPE)

a. Is applicable PPE provided for employees? b. Do you have a program to assure that PPE is inspected and maintained?

38. Do you have a corrective action process for addressing individual safety and health performance deficiencies?
39. Equipment and Materials:

a. Do you have a system for establishing applicable health, safety, and environmental specifications for acquisition of materials and equipment?

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

c. Do you maintain operating equipment in compliance with regulatory requirements?

d. Do you maintain the applicable inspection and maintenance certification records for operating equipment?
40. Subcontractors

Do you use subcontractors? (If no, skip to next question)

a. Do you use safety, health and environmental performance criteria in selection of subcontractors?

b. Do you evaluate the ability of subcontractors to comply with applicable safety, health and environmental requirements as part of the selection process?

c. Do your subcontractors have a written safety, health and environmental program?

d. Do you include your subcontractors in:

Safety, Health and Environmental Orientation Safety, Health and Environmental Inspections

Safety, Health and Environmental Meeting Safety, Health and Environmental Audits
41. Inspections and Audits

a. Do you conduct Safety, Health and Environmental inspections? b. Do you conduct Safety, Health and Environmental program audits?

c. Are corrections of deficiencies documented?

SAFETY, HEALTH & ENVIRONMENTAL TRAINING

42. Safety, Health & Environmental Training

a. Do you know the regulatory safety, health and environmental training requirements for your employees?

b. Have your employees received the required safety, health and environmental training and retraining and is it documented?

c. Do you have a specific safety, health and environmental training program for supervisors?

d. Are all employees trained in the work practices needed to safely perform his/her job?

e. Is each employee instructed in the known potential of fire, explosion, or toxic release hazards related to his/her job, the process and the applicable provisions of the
emergency action plan?

CRAFT TRAINING AND ASSESSMENT

Data timeframe From: To:

Notes
1. Data should be the best available applicable for your company's workforce (use average of last twelve months)
2. Training, Skills Assessment Testing and Performance Verification refer to nationally recognized programs such as NCCER, NCCCO and DOL BAT programs.
If not applicable, please explain

43. Workforce # %

a. Journeymen

b. Sub-Journeyman Trainees (NCCER or DOL BAT covered)

c. Helpers

d. Non-covered Journeymen Craftsmen

e. Non-covered Sub-Journeymen Craftsmen/Trainees/Helpers

f. Supervision (Foremen/General Foremen)

g. Professional (Safety/Scheduling/Engineering)

h. Administration/Management

i. Total Workforce

44. Do you have written Workforce Development Policies and Procedures?

45. Formal Training For Sub-Journeyman Trainees

a. Do you have and maintain craft training records for employees? b. Do you provide incentives to trainees to complete formal training?
c. Percent of sub-journeymen trainees that have completed all NCCER curriculum or DOL Bureau of Apprenticeship Training and graduated %

d. Percent of sub-journeymen trainees presently enrolled in NCCER or DOL BAT Programs %

e. Is Company an accredited NCCER Training Sponsor or Unit?

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46. Assessments, Upgrade Training & Certification # %

a. Journeymen craftsmen who have been assessed through the craft skills assessment process (see note 2)

b. Journeyman Craftsmen who have been certified through written skills assessment testing?

c. Journeyman Craftsmen who have been certified in more than one craft?

d. Journeymen craftsmen with skills deficiencies identified through assessment testing and receiving upgrade training?

e. Journeymen craftsmen in upgrade training to improve areas identified through assessment testing?

f. Do you provide incentives for journeymen to become certified? g. Do craftsmen have access to upgrade training to improve skills?

h. Is Company an accredited NCCER Assessment Center

i. When are craftsmen assessed? Pre-employment Within 30 days of hire Other:

47. Performance Verification # %

a. Journeymen craftsmen that have achieved verified performance

b. Journeymen craftsmen that have achieved both written certification and verified performance.

COMMENTS/EXPLANATIONS
COMMENTS/EXPLANATIONS

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 INFORMATION SUBMITTAL
Please provide copies of checked items with the completed PQF:

EMR documentation from your insurance carrier Safety, Health Environmental Training Schedule (Sample)

Insurance Certificate(s) Safety, Health Environmental Training for Supervisors (Outline)

OSHA 200 and 300 Logs (Past 3 Years) Copy of Louisiana Contractor's Licence

Safety, Health Environmental Program Organization Chart

Safety, Health Environmental Incentive Program List of major equipment (e.g., cranes, JLGs, forklifts) your company has available fo

Substance Abuse Program (Include Substances Tested Levels) Equipment Lockout and Tagout (LOTO)

Hazard Communication Program Confined Space Entry

Respiratory Protection Program Fall Protection, Scaffold use, scaffold building

Housekeeping Policy Personal Protective Equipment

Accident/Incident Investigation Procedure Portable Electric / Power Equipment

Unsafe Condition Reporting Procedure Vehicle Safety

Safety, Health Environmental Inspection Form Compressed Gas Cylinders

Safety, Health Environmental Audit Procedure or Form Electrical Equipment Grounding Assurance

Safety, Health Environmental Orientation (Outline) Emergency Preparedness, including evacuation plan

Safety, Health Environmental Training Program (Outline) Waste Disposal

Example of Employee Safety, Health Environmental Training Records Back Injury Prevention

Workforce Development Policies Heat Stress Prevention

NDT Radiography Program

Fill in below Name & Title of Company Officer responsible for assuring the accuracy of this document:

Name Title Date

Update

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