Vendor #: ______________

Security Agreement Dated:

___________________

CONTRACTOR’S SAFETY QUESTIONNAIRE (Global)

Required when EMR and Published Safety Data not available

Date _______/_______/______

REPLY TO: OWENS CORNING

2790 Columbus Road, Route 16
Granville, Ohio 43023-1200
Attn.:__________________Phone _____________Fax: ____________ E-Mail:
______________________

A. GENERAL INFORMATION

Name of Business

_________________________________________________________

Previous Name(s)

__________________________________________________________

Street Address

____________________________________________________________

Mailing Address

___________________________________________________________

Country _____________________________

City ______________________________District_________

Zip_____________

Contact _______________________________Title

________________________
 Telephone (____) _______-__________ Fax (____) ________-

__________

E-Mail Address __________________________

A. Organization and Work General Information

• Permanent office staff Number _______________

• In-house architects/engineers Number _______________
• Field construction management Number _______________
• Professional Safety Engineers Number________________

• Average years experience In-House ___________

• Average number of field construction workers (typical

project)_____________________________

• Fabricating shop locations, size, and description

(describe)_________________________________

Indicate the types of work you will self-perform by marking with an “X”. Indicate the types
of work you normally subcontract to others by marking with an “O”.

General Mechanical Electrical Other

___Concrete ___Pre-Eng. Bldg ___Fabrication ___Control

___Asbestos Abate.

___Demolition ___Roofing ___Fire Protection ___Electrical ___Field

Erect Tanks

___Gen. Const. ___Siding ___HVAC ___Instrumentation

___Insulation

___Interiors ___Site Work ___Millwright

___Railroad
___Iron Work ___Piping ___Paving

___Landscaping ___Rigging/Hauling
___Furnace

___Painting ___Sheet Metal ___*Other

*Other (Please
Describe)_____________________________________________________________

C. SAFETY INFORMATION

SAFETY PROGRAM

Do you have a formal, written safety program? ___ Yes ___ No (if yes please attach
copy)
Briefly describe what your program covers.

________________________________________

_________________________________________________________________________
_

_________________________________________________________________________
__

Briefly describe the special safety training provided for your job site supervision.
_________________________________________________________________________
__

_________________________________________________________________________
__
Do you have a program for newly hired or promoted foremen? ____Yes ____No

If "yes", does it include instruction on the following?

Yes No Yes No
Safe work practices ___ ___ First aid procedures ___ ___
Safety Supervision ___ ___ Accident investigation ___ ___
Toolbox Meetings ___ ___ Fire protection and ___ ___
Emergency Procedures ___ ___ investigation ___ ___
New worker orientation ___ ___
Do you have a Safety Orientation program for new hires? ___ Yes ___ No
If "Yes", how do you present this orientation?

Film ___ Slides ___ Handbook ___

Verbal ___ Other ________________________

Which of the following are included in this orientation?

Yes No Yes No
Head Protection ___ ___ First Aid Facilities ___ ___
Eye Protection ___ ___ Emergency Procedures ___ ___
Hearing Protection ___ ___ Toxic Substances ___ ___
Respiratory Protection ___ ___ Trenching/Excavation ___ ___
Safety Harness/Lifeline ___ ___ Signs, Barricades,
Scaffolding ___ ___ and Flagging ___ ___
Perimeter Guarding ___ ___ Electrical Safety ___ ___
Housekeeping ___ ___ Rigging/Crane Safety ___ ___
Fire Protection ___ ___ Permits ___ ___

Do all workers have Personal Protective Equipment?

Hard Hats-Yes
Protective Safety Glasses with attached side shields-Yes
Hearing Protection (Ear Plugs)- Yes
Steel – toe boots- No
Hand Protection (Gloves)- Yes

Do you hold Site Safety Meetings for:

Yes No Frequency
Field Supervisors? ___ ___ _____________________________
Employees? ___ ___ _____________________________
New Hires? ___ ___ _____________________________
Sub-contractors? ___ ___ _____________________________

Do you document the safety training provided to your employees? ____Yes ____No

Do you conduct Project Site Safety Inspections?

___ Yes ___ No Frequency ___________________________________________

Who conducts these inspections?__________________________________________

Does your company conduct pre-task safety planning? _____Yes _____No

Does your company have a safety incentive program for workers ____Yes _____No
Do you require your subcontractors to meet the same safety standards that you employ
and/or follow your safety program? ___ Yes ___ No

Do you pre-qualify subcontractors for safety ____Yes _____No - If no explain why ______
________________________________________________________________________

SAFETY ACCOUNTABILITY

Briefly describe how your job site supervisors are held accountable for safety.
_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Do you have a safety officer/department in your firm? ___ Yes ___ No

Attach a list of professional certifications held by your Safety & Health personnel by name

and title.

What is its authority on a job site?

_______________________________________________

Are accident reports and report summaries sent to the following? If yes, how
often?
NO YES MONTHLY OUARTERLY
ANNUALLY
Field Supervision ___ ____ ________ __________
_________
Vice Pres. Construction ___ ____ ________ __________
_________
President of Firm ___ ____ ________ __________
_________

How are accident records and accident summaries kept? How often are they
reported?

NO YES MONTHLY OUARTERLY

ANNUALLY
Accidents totaled for the
 entire company ___ ____ ________ ___________
__________
Accidents totaled by project ___ ____ ________ ___________
__________
-Subtotaled by Superintendent ___ ____ ________ ___________
__________
-Subtotaled by Foreman ___ ____ ________ ___________
__________

SAFETY DATA
Please provide the following data for the last five years.

Current _____ _____ _____ _____

year year year year year

A. Number of man-hours worked in the year _____ _____ _____ _____

_____

B. Number of restricted workday cases _____ ______ _____ _____

_____

C. Number of lost workday cases _____ ______ _____ ______

_____

D. SAFETY INFORMATION (cont'd)

D. Number of fatalities _____ _____ _____ _____

_____

E. Number of cases defined as _____ _____ _____ ______

_____
recordable but not included
in lines B, C, or D above

F. Total number of recordable cases _____ _____ _____ ______

_____
(lines B thru E)

G. Calculate your incidence rate by

using the following formula:
No. recordable cases X 200,000 ______ _____ _____ _____
______
 Man hours

YOU MUST ENCLOSE WITH THIS QUESTIONNAIRE (1)

COPIES OF
EACH INJURY REPORT LISTED IN SECTION B, C, D, & E
ABOVE

Submitted by: __________________________________

Title: __________________________________
Date: __________________________________