GZA Main menu GZA Subcontractor Health & Safety Evaluation Questionnaire In order to manage risks posed by high-hazard activities performed by GZA subcontractors, GZA has instituted a subcontractor health and safety prequalification process. The activities your company may perform could expose your personnel to hazardous chemicals or wastes in the performance of their tasks. Therefore, requirements up to, and possibly including, OSHA standard 29 CFR 1910.120 (entitled Hazardous Waste Operations and Emergency Response) may be applicable to subcontractor services. Your company is required to recognize and comply with any OSHA or other regulatory requirements applicable to their services. Current Company Information Complete Indicates required field Company Information Company Name Company Address NAICS Code Company Phone Number Company's Highest Ranking Safety Contact Contact Email GZA Employee Requesting Evaluation Specific services your company provides to GZA Safety Info NUMBER OF FATALITIES (OSHA 300 LOG COLUMN G) IN PREVIOUS THREE YEARS Use data from your company OSHA 300 log and 300A Summary log to complete the form below. For the EMR, list the interstate rate unless only an intrastate rate is available. (TRIR and DART rates equals number of OSHA recordable injuries times 200,000 divided by the total number of man-hours worked) Fatalities Last Year Fatalities Two Years Ago Fatalities Three Years Ago Experience Modification Rate (EMR) in previous three years EMR Last Year EMR Two Years Ago EMR Three Years Ago Number of OSHA recordable incidents (OSHA 300 LOG column A) in previous years OSHA Recordables Last Year OSHA Recordables Two Years Ago OSHA Recordables Three Years Ago Total Recordable Incidence Rate (TRIR) in previous three years Total Recordable Incident Rate (TRIR) Last Year Total Recordable Incident Rate (TRIR) Two Years Ago Total Recordable Incident Rate (TRIR) Three Years Ago Total number of OSHA Recordable Incidents involving lost workdays, restricted workdays, or job transfers in previous three years Total Number of OSHA Recordable Incidents involving Lost Workdays, Restricted Workdays, or Job Transfers Last Year Total Number of OSHA Recordable Incidents involving Lost Workdays, Restricted Workdays, or Job Transfers Two Years Ago Total Number of OSHA Recordable Incidents involving Lost Workdays, Restricted Workdays, or Job Transfers Three Years Ago Days away, Restricted, or transfer rate in previous three years Days Away, Restricted, or Transfer Rate Last Year Days Away, Restricted, or Transfer Rate Two Years Ago Days Away, Restricted, or Transfer Rate Last Three Years Average Number of Employees Avg Number of Employees Last Year Avg Number of Employees Two Years Ago Avg Number of Employees Three Years Ago Employee Hours Employee Hours Worked (excluding vacations and holidays) Last Year Employee Hours Worked (excluding vacations and holidays) Two Years Ago Employee Hours Worked (excluding vacations and holidays) Three Years Ago Citations If your company received any citations in the last 3 years from any government agencies, such as OSHA or EPA, upload a file describing each citation, action your firm took in response, and resolution. Include information as to the disposition of the citation. If there is no citations received in the last 3 years, check on No citations received in the last 3 years. Has your company recived citations in the last 3 years? Yes No Describe each citation, action your firm took in response, and resolution Employee Training Respiratory Protection Yes No Hazard Communication Yes No 40-hr HAZWOPER Yes No Hazard Recognition/Hazard Assessment Yes No Lockout/Tagout Yes No Hearing Conservation Yes No Heat Stress Yes No Personal Protective Equipment Yes No Electrical Safety Yes No Fork Lift/Industrial Powered Trucks Yes No Is an employee “craft” training program in place? Yes No If there is employee “craft” training program, please describe Upload Drug and Alcohol Program if available One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Does your company have a medical surveillance program conducted in accordance with 29 CFR 1910.120(f)? Yes No If yes, who administers the program Have your activities resulted in property damage great than $1,000.00 within the past three years, including disturbing of underground utilities? Yes No Describe each instance of property damage, action your firm took in response, and resolution Upload Logs Upload OSHA 300 Log (Last Year) One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload OSHA 300 Log (Two Years Ago) One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload OSHA 300 Log (Three Years Ago) One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload OSHA 300A Log (Last Year) One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload OSHA 300A Log (Two Years Ago) One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml.. Upload OSHA 300A Log (Three Years Ago) One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml.. Upload EMR (Last Year) *Using insurance-carrier letterhead One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload EMR (Two Years Ago) *Using insurance-carrier letterhead One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload EMR (Three Years Ago) *Using insurance-carrier letterhead One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Upload Table of Contents of Health and Safety Program One file only. 2 MB limit. Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml. Insurance Do you agree to the following Insurance Requirements? Yes No Does your firm agree to provide, pay for, and maintain in force at all times during the performance of any services for GZA and for the applicable warranty period, insurance in compliance with the example Certificate of Insurance (provided below) and of the Prime Contract, whichever is greater? Click here for example insurance certificate Do you agree to the following requirement? Yes No Your firm shall name GZA and the Owner/Client as "additional insured" on a primary and non-contributory basis for all policies, with the exception of Professional Liability. All policies shall contain a complete waiver by the insurer of subrogation against GZA and the Owner/Client. All such insurance policies shall contain a provision prohibiting cancellation except upon at least thirty (30) days prior notice to GZA, and will be primary in the event of a loss arising out of Subcontractor's performance and shall provide that where there is more than one insured, the policy will operate, except for the limits of liability, as if there were a separate policy covering each insured. Upload Certificate of Insurance Evidencing Required Coverages One file only. 2 MB limit. Allowed types: png, pdf, doc, docx. Officer Information Officer Name Officer Title *Misrepresentation of data requested is grounds for immediate termination of current subcontracts and disqualification from future consideration* Check to Confirm I Confirm the information provided in this form is current and correct GZA Menu Footer Customer Tools Subcontractor Registry Large File Transfer Get In Touch! Contact Us Offices Careers Social menu © 2021 GZA GeoEnvironmental, Inc.