Form Preview Example

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

Page 1 Rev 2/25/2004

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.

1. Air Conditioning / Refrigeration

12. Instrumentation

Comfort Cooling / HVAC

General

Process Refrigeration

DCS Control Systems

2. Buildings

13.

Insulation

Remodeling

General

New (steel, brick, block, other)

Asbestos Abatement

3. Cleaning

14.

Linings/coatings for:

Industrial

Metal

Janitorial

Concrete

4. Civil

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

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)

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

20. Consulting

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:

Page 2 Rev 2/25/2004

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:

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?
				citations in the last three years?

		Page 3 Rev 2/25/2004

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?

Management commitment and expectations

2. Employee participation

Accountabilities and responsibilities for managers, supervisors, and employees

4. Resources for meeting safety, health

environmental requirements.

Periodic safety and health performance appraisals for all employees

6. Safety, Health Environmental Recognition Program

Hazard recognition and control

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

Ensuring your employees follow the safety rules

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?

Page 4 Rev 2/25/2004

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

	Page 5 Rev 2/25/2004

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
	h. Is Company an accredited NCCER Assessment Center

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

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

Page 6 Rev 2/25/2004

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

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

	Safety, Health	Environmental Program		Organization Chart
	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
	Safety, Health	Environmental Incentive Program

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

	Hazard Communication Program			Confined Space Entry
	Hazard Communication Program			Confined Space Entry

	Respiratory Protection Program			Fall Protection, Scaffold use, scaffold building
	Respiratory Protection Program			Fall Protection, Scaffold use, scaffold building

	Housekeeping Policy			Personal Protective Equipment
	Housekeeping Policy			Personal Protective Equipment

	Accident/Incident Investigation Procedure			Portable Electric / Power Equipment
	Accident/Incident Investigation Procedure			Portable Electric / Power Equipment

	Unsafe Condition Reporting Procedure			Vehicle Safety
	Unsafe Condition Reporting Procedure			Vehicle Safety

	Safety, Health	Environmental Inspection Form		Compressed Gas Cylinders
	Safety, Health	Environmental Inspection Form		Compressed Gas Cylinders

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

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

	Safety, Health	Environmental Training Program (Outline)		Waste Disposal
	Safety, Health	Environmental Training Program (Outline)		Waste Disposal

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

	Workforce Development Policies			Heat Stress Prevention
	Workforce Development Policies			Heat Stress Prevention

	NDT Radiography Program
	NDT Radiography Program

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

Name			Title			Date

Page 7 Rev 2/25/2004

Question	Answer
Form Name	Standard Pre Qualification Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	pre qualification form, sample subcontractor prequalification form, subcontractor prequalification form, qualification form pre

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