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.

  • Company Information
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Company Information

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)

Days away, Restricted, or transfer rate in previous three years

Average Number of Employees

Employee Hours

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?

Employee Training

Respiratory Protection
Hazard Communication
40-hr HAZWOPER
Hazard Recognition/Hazard Assessment
Lockout/Tagout
Hearing Conservation
Heat Stress
Personal Protective Equipment
Electrical Safety
Fork Lift/Industrial Powered Trucks
Is an employee “craft” training program in place?

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)?
Have your activities resulted in property damage great than $1,000.00 within the past three years, including disturbing of underground utilities?

Upload Logs

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.

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.

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.

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.

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..

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..

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.

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.

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.

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?
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?
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.

One file only.
2 MB limit.
Allowed types: png, pdf, doc, docx.

Officer Information

*Misrepresentation of data requested is grounds for immediate termination of current subcontracts and disqualification from future consideration*

Check to Confirm