Safety Qualification Form INSTRUCTIONS Complete all yellow cells with accurate responses. "Information provided shall apply to any and all construction work the Firm has completed as Prime, Joint Venture Partner or Subcontractor." 1. Contact Information Company Name: Company Address: Street "City, State, Zip Code" Telephone Number Company Representative Name Company Representative Email Company Representative Phone Number 2. Acknowledgement Please print and sign a hard copy of your Safety Qualification Form. "By signing this Safety Qualification Form, the undersigned certifies under penalty of perjury that signer personally reviewed all information contained in this submittal and certifies that all information provided is complete, accurate, and contains no false or misleading information. " Signature Name: Title Date: 3. Documents to Submit with this Form 3.a. Submit the past three years of your firm's OSHA 300A forms. "3.b. If required to complete Step 3 (below), submit the following documents:" 3.b.1. Additional documents specified in Step 3. "3.b.2. Explanation of any OSHA violations identified in Step 3, below" "3.b.3. Explanation of any fatalities identified in Step 3, below" PRT may in its sole discretion adjust your firm's Safety Qualification status based on information in the above-referenced documents submitted with this form. Step 1 4. Occupational Safety and Health Administration (OSHA) For 300A Summary of Work-Related Injuries and Illness "4a. Please provide your firm's data from your OSHA 300A forms. The data should be for all construction work your firm performed wether as a prime, as part of a joint venture or as a subcontractor." Year 2017 2018 2019 Total number of deaths (G) Total Number of Cases with days away from work (H) Total Number of cases with job transfer or restriction (I) Total number of other recordable cases (J) Average number of Employees Total hours worked by all employees 2017 Total recordable case rate (Automatically Calculated): 2018 Total recordable case rate (Automatically Calculated): 2019 Total recordable case rate (Automatically Calculated): "2017 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated):" "2018 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated):" "2019 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated):" 4b. Enter the North America Industrial Classification System (NAICS) rate associated with your industry from this source: Provide the NAICS Industry Code from your 2018 300A form: Please provide the following information from this source: https://www.bls.gov/iif/oshwc/osh/os/summ1_00_2018.htm "Please type in the ""Industry"" category name for your firm's NAICS code:" "Please provide your industry's ""Total Recordable Cases"" Rate:" "Please provide the Current ""Total Work Loss"" Rate:" "4c. Is your firm's recordable case rate worse than industry standard for two of the last three years? (Automatically Calculated)" "5. Has your firm received an OSHA Serious, Willful or Repeat violation in the last three years, regardless of appeal status? Yes or No" "6. Has your firm experienced a workplace fatality in the last three years? Yes or No" "If you answered ""No"" to every question above (4.c., 5 and 6), you do not need to complete Steps 2 or 3, below. " "If you answer ""Yes"" to any of the questions 4.c., 5 and 6, proceed to Step 2." Step 2 7. Work Loss Rate "7a. Your firm's loss work data from your OSHA 300A forms (Automatically Completed from Q.4a above):" "2017 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated based on information provided in Q4):" "2018 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated based on information provided in Q4):" "2019 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated based on information provided in Q4):" "7b. Your firm's NAICS rate associated with your industry from this source (Automatically Completec from Q.4b above): " The NAICS Industry Code you provided in Q.4: 0 The Industry Category for your firm's NAICS code you provided in Q.4: - The Current Total Work loss Rate you provided in Q4: - "7c. Is your firm's Work Loss rate worse than industry standard for two of the last three years? (Automatically Calculated)" "8. Has your firm received an OSHA Willful or Repeat violation in the last three years, regardless of appeal? Yes or No " "9a. The annual total hours worked for last three (3) years by all employees as reported on your OSHA 300A form (Automatically populated from Q4). " "Total hours worked over last three years (Automatically populated based on information provided in Q.4a)" - "9b. Provide the number of Serious violations issued by OSHA over the past 3 years, regardless of appeal status." "9c. Your serious OSHA violation rate per 200,000 hours (Automatically Calculated)" "9d. Does your firm have more than one serious OSHA violations per 200,000 hours, regardless of appeal status? (Automatically Calculated) " "10. Did OSHA issue your firm a citation for any incident in which there was a fatality in the last 3 years? Yes or No " "If the answers to question 7.c, 8, 9.d and 10 are all ""No"", you do not need to go to step 3" "If you answer ""Yes"" to any questions 7.c, 8, 9.d and 10, proceed to Step 3." Step 3 11. Occupational Safety and Health Administration (OSHA) For 300A Summary of Work-Related Injuries and Illness "Your firm's data for the last three (3) years, as provided in Q.4 (Automatically Populated)." "Current Total Recordable Rate from U.S. Department of Labor for Firm's NAICS (Automatically populated from Q.4b):" - "Current Total Work loss Rate from U.S. Department of Labor for Firm's NAICS (Automatically populated from Q.4b):" - Calculated Rate Possible Points Points Earned for being equal to or better than industry rate (Automatically Calculated) "2017 Total Recordable Rate (Automatically Populated from Q.4a):" 10.00 0 "2018 Total Recordable Rate (Automatically Populated from Q.4a):" 10.00 0 "2019 Total Recordable Rate (Automatically Populated from Q.4a):" 10.00 0 "2017 Total cases with days away from work, job restriction, or transfer rate (Automatically Populated from Q.4a):" 20.00 0 "2018 Total cases with days away from work, job restriction, or transfer rate (Automatically Populated from Q.4a):" 20.00 0 "2019 Total cases with days away from work, job restriction, or transfer rate (Automatically Populated from Q.4a):" 20.00 0 Total OSHA 300A Score: 0 Q.11 - Scoring Rubric - Injury Rates: Recordable Score Lost Workday Score Better than Industry 10.00 20.00 Equal to Industry 5.00 10.00 Worse than Industry 0.00 0.00 12. Safety Document Submittals "Document Available for Submission (Yes or No)" Score possible by submission "Submission Score (Automatically Calculated)" "Evaluation Score (Completed by SFPRT)" Maximum Evaluation Score "Submit Source Documents for each ""Yes"" response at time of Qualification submittal." "12.a. Does your firm have an Injury and Illness Prevention Program? Yes or No" 10 20 "12.b. Does your firm have a Drug and Alcohol Free Workplace Policy? Yes or No" 10 20 "12.c. Does your firm have a Job Hazard Analysis (JHA) Procedure? Yes or No" 5 20 "12.d. Does your firm have a Corporate Safety Manual? Yes or No" 5 20 "12.e. Does your firm have a Injury and Incident Investigation Process? Yes or No" 5 20 "12.f. Does your firms have any Employee Safety Training Programs? Yes or No" 5 20 "12.g. Does your firm have a Safety Field Audit Process? Yes or No" 5 20 "12.h. Does your firm have a Daily Safety Pre-Task Planning Process? Yes or No" 5 20 Total Document Submission Score: 0 Total Document Evaluation Score: 0 Q.12 - Scoring Rubric - Documents: Evaluation of Document Evaluation Score Criteria Below standard - Requires Extensive Improvements 0 Contents of the document do not include most of the critical elements as detailed in document-specific guide. Below standard - Requires Improvements 5 Contents of the document do not include many of the critical elements as detailed in document-specific guide. Below standard - Requires Minor Improvements 10 Contents of the document do not include some of the critical elements as detailed in document-specific guide. Meets Minimum Standard 15 Document contains all of the critical elements as detailed in the document-specific guide with minimal details. Eceeds Minimum Standard 20 Document contains all of the critical elements as detailed in the document-specific guide and embodies a commitment to a culture of safety. 13. OSHA Serious Violations "For Questions 13, 14 and 15, please list violations for all construction work your firm performed wether as a prime, as part of a joint venture or as a subcontractor." "Violations should only be listed once on the correct Question of 13, 14 or 15, as applicable." "On Question 13, please list Federal and State OSHA Serious violations issued over the last three (3) years. " "Please add rows to provide additional citations/violations, as necessary." "Applicant must provide copies of the citation, any appeal and an explanation of corrective actions." Date OSHA Opened Case Citation # Violation # Standard "Citation Information Submitted (Yes or No)" "Appeal Submitted (Yes or No)" "Explanation of Corrective Action Submitted (Yes or No)" "Evaluation Score (Completed by SFPRT)" Total Violation Score: 0 Q.13 Scoring Rubric - OSHA Serious Violations: "When an employer knows of or should know of a situation that has a definite chance of causing serious injury or death, but does not remedy it, OSHA issues a serious violation." "Inspectors must assess a penalty but they can adjust penalties based upon the seriousness of each particular violation, as well as the employer's previous history, the size of the business, and the good faith of the employer. " Serious Violation was associated with or could have lead to this Injury Type; scale of seriousness of violation "Corrective Action Ineffective or Non-Enforceable" "Corrective Action Adequate" "Corrective Action Clear, Enforceable, Implemented, Measured Results" "Sprains/Strain injuries, Contusion/Bruising, Dermatitis" -10 -5 0 "Laceration < 5 stiches, 1st degree burn, Minor eye injury, Back injuries" -10 -5 0 "Laceration 5 to 15 stitches, Corrosive chemical exposure, Chemical inhalation, 2nd degree burn" -15 -10 -5 "Fractures, Hospitalization (overnight of longer), Electrical shock, Severe laceration > 15 stitches, 3rd degree burn" -20 -15 -10 "Work-related Fatality, Amputation, High potential for fatality (Elec shock w/o PPE, Fall w/o fall protection)" -25 -20 -15 14. OSHA Willful and Repeat Violations Provide a description and explanation for each Willful and Repeat violation Date OSHA Opened Case Citation # Violation # Standard "Citation Information Submitted (Yes or No)" "Appeal Submitted (Yes or No)" "Explanation of Corrective Action Submitted (Yes or No)" "Evaluation Score (Completed by SFPRT)" PRT Evaluator shall enter a score in accordance with the Scoring Rubric table for each Willful and Repeat Violation in the last 3 years: Q.14 - Scoring Rubric - Willful and Repeat Violations: Negative Score - Potenitally mitigated by evaluation of explanation OSHA Citation Regulatory Violation General Violation Serious Violation Willful Violation Repeat -10 -25 -100 -200 Willful -30 -50 -200 15. Workplace Fatality Provide a description and explanation for each fatality with citation. Date of Fatality OSHA Citation # OSHA Violation # Description of Incident Submitted (Yes or No) "Citation Information Submitted (Yes or No)" "Appeal Submitted (Yes or No)" "Explanation of Corrective Action Submitted (Yes or No)" "Evaluation Score (Completed by SFPRT)" PRT Evaluator shall enter a score in accordance with the Scoring Rubric table for each fatality in the last 3 years: Q.15 - Scoring Rubric - Workplace Fatalities: Negative Score - Potenitally mitigated by evaluation of explanation No Citation: Personal Medical No Citation: Employee at fault Serious Citation Issued Willful Citation Issued 0 0 -100 -200 STEP 3 SCORE RESULTS Minimum score to pass is 150 Which is 50% of the maximum score of 300 Applicant Score Max Score 11. Occupational Safety and Health Administration (OSHA) For 300A Summary of Work-Related Injuries and Illness: 0 90 12. Safety Document Submittals: 0 210 13. OSHA Serious Violations: 0 14. OSHA Willful and Repeat Violations: 0 15. Workplace Fatality: 0 Total 0 150 Minimum Score Required Weighting of positive score OSHA 300A Q.11 90 30% Documents Q.12 210 70% Maximum Possible Score 300 100%