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

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