alcoa inc. 2007 contractor, subcontractor and contracted services ...

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 1 OF 7
This is an Environment, Health, and Safety Mandated Standard/Procedure - Alcoa Controlled Entities
Worldwide.
All questions must be answered.
Any questions not answered will count negatively against your overall evaluation.
1. Enter date in yyyy-mm-dd format:
2. Legal Name of Company: .
3. Operating Name of Company:
4. Government ID Number:
5. Address:
Street:
City:
State/Province: Postal Code: Country:
6. Contact Name:
7. Contact Title:
8. Contact E-mail Address:
9. Contact Phone Number:
10. Contact Fax Number:
11. Select the one category that best describes services offered by your company.
Contractor or Subcontractor
Contracted Services
1 Concrete/Masonry Contractor 15 Administrative and Employment Support Services
2 Drilling/Excavation/Trenching 16 Equipment Repair and Maintenance Services
3 Electrical Contractor 17 Food Preparation/Distribution Services
4 General/Building Contractor 18 Furnace/Oven Services
5 Glass Installation/Maintenance 19 Janitorial/Cleaning Services
6 Mining/Exploration Contractor 20 Landscaping or Pest Control Services
7 Painting/Wall Covering Contractor 21 Machine Shop Services
8 Plumbing/Heating/Air Conditioning 22 Material Handling Equipment Services
9 Public Utilities Contractor 23 Professional/Scientific/Tech/Environmental Services
10 Roadway/Highway Contractor 24 Suppliers of Machinery/Equipment/Goods Services
11 Roofing/Siding/Sheet Metal 25 Telecommunication Services
12 Site Preparation/Demolition Contractor 26 Transportation/Trucking/Hauling Services
13 Other Specialty Site Contractor 27 Uniform Cleaning and Laundry Services
14 Structural Steel Erection 28 Waste Collection, Treatment and Disposal Services
30 Other/General Contractor 29 Waste Remediation Services
30 Other/General Services
Enter the one category number from the list above:
If you selected category “30”, describe your services:
PLEASE ENTER FROM THE LIST ABOVE
12. As part of your company’s safety process, are safety hazard assessments conducted and written job
specific safety plans prepared to eliminate safety hazards?
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 2 OF 7
If “Yes”, please attach examples.
Explain your company’s usual process to eliminate safety hazards
13. At what frequency does your company conduct and document safety activities, such as safety
orientations, or safety meetings, or safety inspections?
A. Daily
B. Weekly
C. Monthly
D. Conducts a safety orientation only.
E. None of the above.
Comments:
14. Do the following participate in the investigation of all significant incidents or accidents?
A. Owner or Senior Management.
B. Middle Management.
C. Lead Person.
D. Other.
If “Other” is “Yes”, please specify:
15. Have the following changed for your company in the last 3 years?
A. Ownership.
If “Yes”, please provide details.
B. Insurance Carrier.
If “Yes”, please provide details.
C. Other significant changes which may favorably affect safety.
If “Yes”, please provide details.
16. Check all answers that describe the content of your company’s safety training.
A. Basic safety training complies with all local regulations and consensus standards.
B. Select crafts and trades have completed advanced safety training beyond regulatory
requirements.
If “Yes”, please describe specific safety training.
C. Select crew leaders have completed advanced safety training beyond regulatory requirements.
If “Yes”, please describe specific safety training.
17. Documentation of basic safety training exists in the form of:
A. Internal certifications and records.
B. External licenses and certificates issued by governments, professional organizations, trade
associations or other recognized authority.
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 3 OF 7
If “Yes”, please attach an example or certificate issued by a recognized authority.
18. What percent of the work force has been working in the industry for 1 year or more?
A. 0% - 25%
B. 26% - 50%
C. 51% - 75%
D. 76% - 100%
Comments:
19. Your company has a lead person to crew ratio of:
A. Less than or equal to 1 to 7
B. Between 1 to 8 and 1 to 11
C. Between 1 to 12 and 1 to 25
D. Greater than 1 to 25
Comments:
20. The criteria used to qualify safety trainers is established by:
A. Internal training and certifications.
If “Yes”, please describe:
B. External training and certifications from governments, professional organizations, trade associations
or other recognized authority.
If “Yes”, please describe:
21. Safety and scheduling coordination meetings with subcontractors are held:
A. Daily
B. Weekly when work is for longer than 1 week.
C. As needed.
D. No Subcontractors are used.
Comments:
22. Indicate all that apply to your company’s substance abuse program.
A. Substance abuse is monitored using random substance tests.
B. Substance abuse is monitored using substance tests for cause or post incident.
C. Substance abuse is monitored by crew leaders trained in substance abuse recognition.
Comments:
23. Your company audits and documents safety meetings, job safety conditions or job safety performance at
the rate of:
A. Daily
B. Weekly
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 4 OF 7
C. Monthly
D. Does not audit these.
If audits are performed, please attach the written results from a safety audit.
Comments:
24. How often does the owner or the senior management of your company review the safety performance of
work crews?
A. Weekly
B. Monthly
C. Quarterly
D. Other
If “Other”, please explain:
25. Indicate all of the following that have occurred within the last 5 years to any personnel employed or
contracted by your company while working.
A. A serious or disabling injury occurred due to any event. Examples of events which could cause a
serious or disabling injury include excavation or trench collapse, scaffold failure, confined space entry
incident, mobile equipment rollover or contact with electricity.
If “Yes”, please attach details of the injury, the cause and the implemented corrective actions.
B. A serious or disabling injury occurred due to ergonomic factors. Examples of activities would include
lifting, pulling, bending, reaching, and vibration resulting in strains or sprains.
If “Yes”, please attach details of the injury, the cause and the implemented corrective actions.
C. A fatality occurred to anyone, including any personnel, visitor, member of the public or any other
person due to any circumstances controlled by your company.
If “Yes”, please attach details of the fatality, the cause and the implemented corrective actions.
26. Does a government agency or any other group, such as an insurance carrier, require a log, record or
similar document of reportable work related injuries or illnesses? Examples are OSHA Logs, workers
compensation claims reports, insurance register of accidents, HSA report, RIDDOR, and etc.
If “Yes”, please attach copies for the last 3 years.
Comments:
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 5 OF 7
27. Enter the following information for the last three years for the total company:
A. Total number of lost workday and restricted
work cases (not number of days lost/restricted). 0
B. Total number of medical treatment cases 0 0
2004 2005 2006
C. Total number of first aid cases 0 0 0
D. Total number of injury free events reported
E. Total hourly and salaried hours reported
F. Accident insurance premium multiplier 0.00 0.00 0.00
28. If you do not have an accident insurance premium multiplier, please explain. Examples of an accident
insurance multiplier are: Experience Modification Rate, EMR, Performance Index, Insurers Risk
Rating, and etc.:
29. Did your company receive any serious, repeat or criminal citations for health or safety in the last 3 years
that involved:
A. Work at a customer’s site, but no injuries or fatalities occurred?
If “Yes”, please describe.
B. Work at a customer’s site where injuries or fatalities occurred?
If “Yes”, please describe.
C. Any work other than at a customer’s site, but no injuries or fatalities occurred?
If “Yes”, please describe.
D. Any work other than at a customer’s site, where injuries or fatalities occurred?
If “Yes”, please describe.
30. Has your company worked at Alcoa locations during the last 3 years?
A. Routinely, more than 3 times.
B. Periodically, 2, or 3 times.
C. Once or never before.
Below please identify Alcoa locations where you’ve provided work within the past 3 years.
1. Location:
Contact:
Dates:
Scope of Work:
2. Location:
Contact:
Dates:
Scope of Work:
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 6 OF 7
3. Location:
Contact:
Dates:
Scope of Work:
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072

ALCOA INC. 2007
CONTRACTOR, SUBCONTRACTOR AND CONTRACTED SERVICES 33.055.1
ANNUAL PREQUALIFICATION FORM – SAFETY PAGE 7 OF 7
Submittal Instructions to PURCHASING SERVICES CO.
A. Please complete and save this document on your desktop or local drive. Then submit this entire
document and any attachments electronically to Purchasing Services Co. at REQS@PS-C.COM
(clicking on this link will open a new e-mail message for you to send).
Print, sign, and fax this last page only to Purchasing Services Co. at 1-724-335-6312.
If attachments cannot be sent electronically and are less than 60 pages, you may fax them, otherwise
please mail to:
Purchasing Services Co.
830 Fifth Avenue
New Kensington, PA 15068
USA
B. If this form was not requested directly by Purchasing Services Co., who sent it to you?
Person requesting:
Facility requesting:
C. Contact information:
Company: .
Name:
Title:
E-mail:
Phone number:
Fax number:
Completed by:
Troy Kidwell / Bob Sherman
D. Identify each attachment with question number and suffix if applicable and indicate below which
attachments are being submitted, unidentified attachments will not be considered:
Q 12. Examples of safety hazard assessment and written job specific safety plan
Q 17.
Q 23.
Example of a certificate issued by a recognized authority
Results from an audited safety meeting, job safety conditions or job safety performance
Q 25A. Details on serious or disabling injury from catastrophic event(s), including the cause and
implemented corrective actions
Q 25B. Details on serious or disabling injury from ergonomic factors, including the cause and
implemented corrective actions
Q 25C. Fatality details, including the cause and implemented corrective actions
Q 26.
Log or record of work related injuries and illnesses
E. By signing below, I certify that all statements provided herein are true and correct.
Signature: ___________________________________
This document is the property of Alcoa Inc. and must be returned on request. It shall not be reproduced or copied, in whole or in part, or used on behalf of others than Alcoa Inc. or its
subsidiaries, without permission. It is provided solely for the purpose of disclosing Alcoa's approach and is not intended to be a recommendation for any recipient other than Alcoa. No
warranties, guarantees or representations, express or implied are made as to the utilities or effectiveness of the methods, processes, products or procedures described or recommended herein.
Rev. 2_20072