GZA Subcontractor Registry

GZA GeoEnvironmental, Inc.
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.

Bidder Health and Safety Submission Checklist

  Submit With
This
Questionnaire
Submit To GZA
Contact Prior To
Mobilization
Completed Questionnaire
(Submit Health & Safety Evaluation Registration online. Link at the bottom of this page)
X  
OSHA 300A/300 logs for previous 3 years X  
EMR rates for previous 3 years on insurance-carrier letterhead X  
Table of Contents of Health and Safety Program X  
Drug and Alcohol Program X  
Copies Of Employee Training Certificates And Medical Surveillance Clearances (for each employee participating in on-site activities)   X
Medical Clearance Sheets for any employees who will work on a GZA project site   X
Chemical Inventory and chemical Safety Data Sheets for any chemicals you bring to a GZA project site   X

 

GZA Health & Safety Evaluation Registration Form is a web based electronic form. Please answer the questions in the form completely, upload the requested information in allowable format, and submit the form after all required fields are filled out.

MISREPRESENTATION OF DATA REQUESTED IS GROUNDS FOR IMMEDIATE TERMINATION OF CURRENT SUBCONTRACTS AND DISQUALIFICATION FROM FUTURE CONSIDERATION.
 

Important Information about File Upload
Acceptable file types including: gif, jpg, png, bmp, txt, pdf, doc, docx, xls, xlsx.
(Any other file type will not be accepted by the system)

If your company is exempt from maintaining OSHA logs or does not qualify for an Experience Modification Rate (EMR): create a short document describing the exemption(s) and upload it each time this questionnaire requires an OSHA log and/or EMR file to be uploaded. Without this information the questionnaire will not submit correctly and the evaluation of your company will be delayed.

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)
Experience Modification Rate (EMR) in Previous Three Years
Number of OSHA Recordable Incidents (OSHA 300 Log Column A) in Previous Years
Total Recordable Incidence Rate (TRIR) in Previous Three Years
Total Number of OSHA Recordable Incidents involving Lost Workdays, Restricted Workdays, or Job Transfers in Previous Three Years
Days Away, Restricted, or Transfer Rate in Previous Three Years
Average Number of Employees
Employee Hours Worked (excluding vacations and holidays) in Previous Three Years
You will be asked to attach copies of OSHA 300A/300 logs and EMR rates (using insurance-carrier letterhead) for previous 3 years using the upload fields at the bottom of this form.
Has your company received citations in the last 3 years?
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.
Employee Training
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Upload OSHA 300A/300 logs and EMR rates for previous 3 years
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Insurance:
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?
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.
Files must be less than 2 MB.
Allowed file types: png pdf doc docx.
Please provide the name and title of an officer of the company to confirm and certify that the information provided in this form is current and correct.
*Misrepresentation of data requested is grounds for immediate termination of current subcontracts and disqualification from future consideration*