CONTRACTOR PRE-QUALIFICATION GUIDELINE

Attachment 1 Tender No. QAL-TEC-0060-20

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

2. Officers Years with Company

President/CEO
Vice-President/CEO
CFO
3. How many years has your organization been in business under your present company name?

4. Parent Company Name:

Telephone: Fax:
City: Country Postal Code:
Subsidiaries:

5. Under current management since (date):

6. Contact for Requesting Bids:

Title: Telephone #: Fax #:

7. Guideline completed by:

Title: Telephone #: Fax #:

ORGANIZATION
8. Form of Business Sole Owner Partnership Corporation
9. Percentage Owned:
10. Describe Services Performed:
Construction Maintenance
Original Manufacturer and Installer Service Work (e.g. janitorial, clerical, etc.)
Project Management Workforce and Resources
Original Equipment Manufacturer and Construction Design
Other – describe below:
11. Describe Services Performed:

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12. List other types of work within the services you normally perform that you subcontract to
others (including brokers):

13. Do you evaluate your sub-contractors HSE/safety program? Yes No

14. Attach a list of major equipment (e.g. cranes , JLGs, forklifts) the company has available for
work and the method of establishing competency to operate.

15. Describe any affiliations with labor organizations

16. Annual US$ dollar volume of the past three years 20____ 20___ 20___
$ $ $

17. Largest job during the last 3 years: $

18. Your firm’s desired project size: Maximum: Minimum:
19 Financial Rating: D&B: Net Worth:
20. Major jobs in progress:
Customer/Location Type of Work Size US$ Customer Telephone
Contact

21. Major jobs completed in the past three years:

Customer/Location Type of Work Size US$ Customer Telephone
Contact

22. Are there any judgements, claims or suits pending or outstanding against your company?
Yes No
If Yes, please attach details
23. Are you now or have you ever been involved in any bankruptcy or reorganization
proceedings? Yes No
If Yes, please attach details

HEALTH, SAFETY and ENVIRONMENT Performance

24. From last three years (including sub-contractors) 2016 2017 2018
 No. of fatalities?
 No of lost time incidents?
 No. of medical aid injuries? ________ ________ ________
 Do you have a modified work program? Yes No

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25. List the past three years Injury Incidence Rate (including sub-contractors)

________________,2017 _________________, 2018 _______________,2019

# of Lost Time Injuries x 200,000

Total Employee Hours (yearly)

26.

HEALTH, SAFETY and ENVIRONMENT Management

27. Highest ranking HSE/safety professional in the organization:
Name Telephone Fax
Title:____________________ __________________ ____________________

HSE/Safety Professional Team

Name __________________ __________________ ____________________

Name __________________ __________________ ____________________

28. Does the Contractor have or provide:

a. Full time Health, Safety and Environment resources? Yes No
b. Full time site Health, Safety and Environment resources?
Home office Yes No
Field Yes No

29. Is there a written Health, Safety and Environmental Program? Yes No

Does the program address the following key elements?
 Management commitments Yes No
 Employee participation Yes No
 Accountabilities and responsibilities for managers, supervisors
and employees Yes No
 Resources for meeting Health, Safety and Environment requirements Yes No
 Periodic Health, Safety and Environment performance appraisals
for all employees Yes No
 Hazard recognition and control Yes No

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32 Does the program include work practices and procedures such as:
a. Equipment lockout Yes No
b. Confined space entry Yes No
c. Injury & illness recording Yes No
d. Fall protection Yes No
e. Personal protective equipment Yes No
f. Portable electrical/power tools Yes No
g. Vehicle safety Yes No
h. Compressed gas cylinders Yes No
i. Electrical equipment grounding assurance Yes No
j. Powered industrial vehicles(cranes, forklifts, JLGs, etc.) Yes No
k. Housekeeping Yes No
l. Accident/incident reporting Yes No
m. Unsafe condition reporting Yes No
n. Emergency preparedness, including evacuation plan Yes No
o. Waste disposal Yes No

33 Are there written programs for the following?

a. Hearing conservation program Yes No
b. Respiratory protection Yes No
Where applicable, have employees been:
 Trained Yes No
 Fit tested Yes No
 Medically approved Yes No

c. MSDS Yes No

34 Is there a substance abuse program? Yes No

If Yes, does it include the following?
 Pre-employment Yes No
 Random testing Yes No
 Testing for cause Yes No

35 Medical
a. Do you conduct medical examinations for:
 Pre-employment Yes No
 Replacement job capability Yes No
 Pulmonary Yes No
 Respiratory Yes No
b. Describe how first aid and medical services will be provided for employees while on-site.
Specify who will provide this service:________________________________________

c. Are there personnel trained to perform first aid and CPR? Yes No

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36 Are safety meetings held for:

 Field Supervisors Yes No Frequency ______
 Employees Yes No Frequency ______
 New Hires Yes No Frequency ______
 Subcontractors Yes No Frequency ______

Are the Health, Safety and Environment meetings documented? Yes No

37 Personal Protection Equipment (PPE)

a. Is applicable PPE provided for employee? Yes No
b. Is there a program to assure that PPE is inspected
and maintained? Yes No

38 Is there a corrective action process for addressing individual Health, Safety and
Environmental performance deficiencies Yes No

39 Equipment and Materials:

a. Is there a system for establishing applicable Health, Yes No
Safety, and Environment specifications for acquisition of
Materials and equipment?
b. Are inspections conducted on operating equipment (e.g. cranes, Yes No
forklifts JLGs) in compliance with regulatory requirements?
c. Is operating equipment maintained in compliance with Yes No
regulatory requirements?
d. Are applicable inspection and maintenance Yes No
certification records mainatained for operating equipment?

40 Subcontractors
a. Is Health, Safety and Environment, performance criteria used in Yes No
selection of subcontractors?
c. Is the ability of subcontractors to comply withapplicable Yes No
Health, Safety and Environment requirements evaluated as part
of the selection process?
c. Do your subcontractors have a written Health, Safety Yes No
and Environment Program?
d. Are subcontractors included in:
 Health, Safety and Environment orientation Yes No
 Health Safety and Environment meetings Yes No
 Inspections Yes No
 Audits Yes No

41 Inspections and Audits

a. Health, Safety and Environment inspections conducted? Yes No
b. Health, Safety and Environment audits conducted? Yes No
c. Are corrections of deficiencies documented? Yes No

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42 Craft Training
a. Are employees trained in appropriate job skills? Yes No
b. Are employees job skills certified where required by Yes No
regulatory or industry consensus standards?
d. List crafts which have been certified:
 ___________________________
 ___________________________
 ___________________________
 ___________________________
 ___________________________

43 Safety Orientation/Induction Program New Hires Supervisors

a. Is there an Health, Safety Yes No Yes No
and Environment orentation program for new
hires and newly hired or promoted
supervisors?
b. Does program provide instruction on:
 New worker orientation Yes No Yes No
 Safe work practices Yes No Yes No
 Safety Supervisors Yes No Yes No
 Tailgate meetings Yes No Yes No
 Emergency procedures Yes No Yes No
 First Aid procedures Yes No Yes No
 Incident investigations Yes No Yes No
 Fire protection and prevention Yes No Yes No
 Safety intervention Yes No Yes No
 MSDS training Yes No Yes No
c. How long is the orentation program? _______hours.

44 Health, Safety and Environment Training

a. Are there regulatory Health, Safety and Environment Yes No
training requirements for employees?
b. Have employees received the required Health & Safety Yes No
training and retraining?
c. Is there a specific Health, Safety and Environment Yes No
training program for supervisors?

45 Training Records
a. Are there Health, Safety and Environment Craft training records Yes No
for employees?
b. Do the training records include the following:
 Employee identification Yes No
 Date of training Yes No
 Name of trainer Yes No
 Method used to verify understanding Yes No

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45. Training Records con’t

c. How is understanding of training verified? (Check all that apply)
 Written test Yes No
 Oral test Yes No
 Performance test Yes No
 Job Observations Yes No

 Other (list) __________________

__________________
__________________
__________________

INFORMATION SUBMITTAL
Are copies of the following items with complete PQF provided:
 Health, Safety and Environment program
 Health, Safety and Environment incentive program
 Substance Abuse program
 MSDS program
 Respiratory Protection program
 Housekeeping policy
 Accident/Incident investigation procedures
 Health, Safety and Environment inspection form
 Health, Safety and Environment audit procdure or form
 Health, Safety and Environment training program (outline)
 Example of employee Health & Safety and Environment training records
 Health, Safety and Environment training schedule (sample)
 Health, Safety and Environment training for supervisors (outline)
 Qualification requirements for Health, Safety and Environment representatives

Individual to contact for clarification or additional information:

Name: __________________________________ Telephone #: _____________________

E-Mail: __________________________________ Fax #: ______________________

OFFICE USE ONLY

Do not fill out - Qatalum use only

Contractor is:
Acceptable for approved contractors list Yes No
Conditionally acceptable for approved contractors list Yes No
Comments/Conditons:

Reviewer: ________________________________________ Date: ____________________

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