Contractors Safety Information Sheet

Presented by: John Bollom

Houston Business Roundtable2010 Safety Excellence Award Training

HBR SAFETY EXCELLENCE AWARD 2008 CONTRACTORS SAFETY INFORMATION SHEET

Nominated by:______________________________________________________________________ *Note: If your firm has received several nominations, copy this form and complete one for each project site

Name of your firm exactly as you wish it published on any brochures, plaques, etc.:

Contact Name: Title:

Address City/State/Zip

Phone: Fax: e-mail:

Type of business/work/service (check the one for which you want to be considered)

General Contractor Large (construction & maintenance)

Specialty Contractors – Hard Crafts (mechanical, I&E, HVAC)

Specialty Contractors – Soft Crafts Small (insulation, painting, scaffolding)

Specialty Contractors – Technical Support (engineering, safety, inspection)

General Contractor Small (construction & maintenance)

Specialty Contractors – Soft Crafts Large (insulation, painting, scaffolding)

Specialty Environmental (hydro blasting, vacuum trucks, chemical cleaning)

Note: For Large and Small categories, placement may be changed based on company total hours

Company Description (Type of work/service your company does)

Use 2007 OSHA No. 300 logs to provide the following injury/illness data:

Project/Work Site Data Total Company Data

a. Total number of OSHA recordable cases.

b. Total number of lost work- day cases which involved days away from work.

c. Total number of fatalities.

d. Total hours worked.

SUBMITTED BY: ____________________________Title ______________________________ PHONE NUMBER: _____________________ E-MAIL:________________________________

Please return this form along with your HBR Safety Awards Initial Evaluation Form and the attachments checked off on the last page of that form to the Houston Business Roundtable, 8031 Airport Blvd., Suite 118 Houston, Texas

77061 by 4:00 p.m. on Monday, February 4, 2008

Houston Business Roundtable2010 Safety Excellence Award Training

Six Sections Nominated By

Name of Firm

Type of Business

Company Description

OSHA Information

Contact Information

2009 CONTRACTORS SAFETY INFORMATION SHEET

Nominated by: ABC Chemicals

*Note: If your firm has received several nominations, copy this form and complete one for each project site

Fill out one form for each project site you have been nominated for.

Section 1: Nominated By

Name of your firm exactly as you wish it published on any brochures, plaques, etc.:

Contact Name: Title:

Address City/State/Zip

Phone: Fax: e-mail:

Name of company as you would like to see it on awards.

Contact name needs to be someone that can answer questions.

Section 2: Name of Firm

Type of business/work/service (check the one for which you want to be considered)

General Contractor Large (construction & maintenance)

Specialty Contractors – Hard Crafts (mechanical, I&E, HVAC)

Specialty Contractors – Soft Crafts Small (insulation, painting, scaffolding)

Specialty Contractors – Technical Support (engineering, safety, inspection)

General Contractor Small (construction & maintenance)

Specialty Contractors – Soft Crafts Large (insulation, painting, scaffolding)

Specialty Environmental (hydro blasting, vacuum trucks, chemical cleaning)

Note: For Large and Small categories, placement may be changed based on company total hours

Check the category for which you want to be considered.

Section 3: Type of Business

Company Description (Type of work/service your company does)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Need a good description of work/service your company performs.

Section 4: Company Description

Project/Work Site Data Total Company Data

a. Total number of OSHA recordable cases.

b. Total number of lost work- day cases which involved days away from work.

c. Total number of fatalities.

d. Total hours worked.

Use 2008 OSHA No. 300 logs to provide the following injury/illness data:

Data needed for both:

• Nominated worksite.

• Total company (All work in the US)

Section 5: OSHA Information

SUBMITTED BY: ____________________________Title ______________________________

PHONE NUMBER: _____________________ E-MAIL:________________________________

Please return this form along with your HBR Safety Awards Initial Evaluation Form and the attachments checkedoff on the last page of that form to the Houston Business Roundtable, 8031 Airport Blvd., Suite 118 Houston,

Texas\ 77061 by 4:00 p.m. on Monday, February 1, 2010

Contact name needs to be someone that can answer questions.

Make certain contact information is correct.

Section 6: Contact Information

Safety Awards Initial Evaluation Form

Houston Business Roundtable2010 Safety Excellence Award Training

Houston Business Roundtable2010 Safety Excellence Award Training

Consist of a five page document

2009 Safety Awards Initial Evaluation Form

Safety Awards Initial Evaluation Form

Five Sections General Information Safety, Health & Environmental Performance Safety, Health & Environmental Management Safety, Health & Environmental

Programs/Procedures Information Submittal

Section 1: General Information

GENERAL INFORMATION

1.Company Name: Telephone:       Fax:    

Street Address:     Mailing Address:      

 

Web site:   

Contact Person:     e-mail:   

Telephone:   Fax:   

2. Parent Company Name:

Once again double check contact information.

GENERAL INFORMATION

1.Company Name: Rohm and Haas Texas, IncTelephone: 281-228-8300     

Fax: 281-228-8178     

Street Address:  1900 Tidal Road     Mailing Address: 1900 Tidal Road      

Maintenance Bldg Rm# 33Maintenance Bldg Rm# 33Deer Park, Texas 77536      

Deer Park, Texas 77536 Web site:   www.rohmhaas.com

Contact Person:   John Bollom    e-mail:   jbollom@rohmhaas.com   

Telephone:  281-228-3415     Fax:   281-228-8178   

2. Parent Company Name:    Rohm and Haas Company  

SAFETY, HEALTH & ENVIRONMENTAL PERFORMANCE

3. Workers Compensation Experience Modification Rate (EMR) Data

b. EMR for three last years:

Interstate rate XXX Intrastate rate

Monopolistic State rateDual rate

YR: 2007 EMR: .XXX YR: 2008 EMR: .XXX   YR: 2009 EMR: .XXX    

c. State of Origin:      Philadelphia, Pennsylvania d. EMR Anniversary Date:       XX/XX/XXXX

e. Standard Industrial Code (SIC):      123456

4. Injury and Illness Data:

a. Total company employee hours worked last three years (excluding subcontractors)

Hours/ Year YR:       YR:       YR:      

Field XXXX XXXX XXXX

TotalXXXXX      

XXXXXX       XXXXX      

Section 2: Safety, Health & Environmental Performance

SAFETY, HEALTH & ENVIRONMENTAL PERFORMANCE

3. Workers Compensation Experience Modification Rate (EMR) Data

b. EMR for three last years:

Interstate rate Intrastate rate

Monopolistic State rateDual rate

YR: 2007 EMR:      YR: 2008 EMR:      YR: 2009 EMR:      

c. State of Origin:       d. EMR Anniversary Date:      

e. Standard Industrial Code (SIC):      

4. Injury and Illness Data:

a. Total company employee hours worked last three years (excluding subcontractors)

Hours/ Year YR:       YR:       YR:      

Field                  

Total                  

Section 2: Safety, Health & Environmental Performance

b. Provide data (excluding subcontractor) using your 300 Forms from the past three (3) years:Notes: (1) Data should be total company data unless specifically requested by client(2) Combine injuries and illnesses from 300 Form

(3) If your company is not required to maintain OSHA 300 forms, please provide information from your Worker’s Compensation insurance carrier itemizing all claims for the last 3 years.

YR:   YR:      YR:    

(4) If data is being provided after July 31st please include current YTD cumulative No. Rate No. Rate No. Rate

FatalitiesRate = Number of Fatalities x 200,000 Total Employee Hours

       

Lost workday case injuries and illnesses involving days away from work, or days of restricted work activity, or both.

Rate = Total LW and restricted cases x 200,000 Total Employee Hours

       

b. Provide data (excluding subcontractor) using your 300 Forms from the past three (3) years:Notes: (1) Data should be total company data unless specifically requested by client(2) Combine injuries and illnesses from 300 Form

(3) If your company is not required to maintain OSHA 300 forms, please provide information from your Worker’s Compensation insurance carrier itemizing all claims for the last 3 years.

YR: 2009      YR: 2008      YR: 2007    

(4) If data is being provided after July 31st please include current YTD cumulative No. Rate No. Rate No. Rate

FatalitiesRate = Number of Fatalities x 200,000 Total Employee Hours

XX 0.XX  XX   0.XX    XX   0.XX   

Lost workday case injuries and illnesses involving days away from work, or days of restricted work activity, or both.

Rate = Total LW and restricted cases x 200,000 Total Employee Hours

XX 0.XX XX 0.XX      XX 0.XX     

Section 2: Safety, Health & Environmental Performance

Lost workday case injuries and illnesses involving days away from work.

Rate = LW cases** x 200.000 Total Employee Hours

Injuries and Illnesses involving medical treatment only.Rate = Total Injuries and Illnesses involving medical treatment only

x 200, 000 Total Employee Hours

Total OSHA Recordable Injury and Illnesses RateRate = Total Injuries and Illnesses x 200,000 Total Employee

Hours

5. Have you received any regulatory (EPA, OSHA, etc.), civil or criminal citations in the last three years?If yes, please attach copies. Yes No

Lost workday case injuries and illnesses involving days away from work.

Rate = LW cases** x 200.000 Total Employee HoursXX 0.XX  XX   0.XX    XX   0.XX   

Injuries and Illnesses involving medical treatment only.Rate = Total Injuries and Illnesses involving medical treatment only

x 200, 000 Total Employee HoursXX 0.XX  XX   0.XX    XX   0.XX   

Total OSHA Recordable Injury and Illnesses RateRate = Total Injuries and Illnesses x 200,000 Total Employee

HoursXX 0.XX  XX   0.XX    XX   0.XX   

5. Have you received any regulatory (EPA, OSHA, etc.), civil or criminal citations in the last three years?If yes, please attach copies. Yes No

Section 3: Safety, Health & Environmental Management

SAFETY, HEALTH & ENVIRONMENTAL MANAGEMENT

6. Name of highest ranking Safety, Health & Environmental professional in the company:

Name:      

Title:      

Certifications:      

Telephone:       Fax:      

This person reports to:       Title:      

7. Do you have or provide:

a. Full time Safety/Health Director Yes No

b. Full time Site Safety/Health Supervisor Yes No

c. Full Time Job Safety/Health Coordinator Yes No

8. Do you have or provide:

a. Safety, Health & Environmental recognition program Yes No

b. Company paid Safety, Health & Environmental training Yes No

SAFETY, HEALTH & ENVIRONMENTAL MANAGEMENT

6. Name of highest ranking Safety, Health & Environmental professional in the company:

Name:     Safety Guru’s Name HERE Title:  Boss    

Certifications:      CSP, OHST, COSS

Telephone:     123-456-7890 Fax:       123-456-7890

This person reports to:     Safety Guru’s Boss Title:      Big Boss

7. Do you have or provide:

a. Full time Safety/Health Director Yes No

b. Full time Site Safety/Health Supervisor Yes No

c. Full Time Job Safety/Health Coordinator Yes No

8. Do you have or provide:

a. Safety, Health & Environmental recognition program Yes No

b. Company paid Safety, Health & Environmental training Yes No

Section 4: Safety, Health & Environmental Programs/Procedures

SAFETY, HEALTH & ENVIRONMENTAL PROGRAMS / PROCEDURES

9. a. Do you have a written S, H & E Program? Yes No

b. Does the program address the following key elements?

1. Management commitment and expectations Yes No

2. Employee participation Yes No

3. Accountabilities and responsibilities for managers, supervisors, and employees Yes No

4. Resources for meeting safety, health & environmental requirements. Yes No

5. Periodic safety, health and environmental performance appraisals for all employees Yes No

6. Safety, Health & Environmental Recognition Program Yes No

7. Hazard recognition and control Yes No

c. Does the program satisfy your responsibility under the law for:

1. Ensuring your employees follow the safety rules of the facility? Yes No

2. Advising owner of any unique hazards presented by the contractor’s work, and of any hazards found by the contractor?

Yes No

Section 4: Safety, Health & Environmental Programs/Procedures

10. Does the program include work practices and procedures such as:

a. Equipment Lockout and Tagout (LOTO) Yes NoN/A

b. Confined Space Entry Yes NoN/A

c. Injury & Illness Recording Yes NoN/A

d. Fall Protection Yes NoN/A

e. Personal Protective Equipment Yes NoN/A

f. Portable Electrical/Power Tools Yes NoN/A

g. Vehicle Safety Yes NoN/A

h. Compressed Gas Cylinders Yes NoN/A

i. Electrical Equipment Grounding Assurance Yes NoN/A

j. Powered Industrial Vehicles (Cranes, Forklifts, JLGs, etc.) Yes NoN/A

Section 4: Safety, Health & Environmental Programs/Procedures

k. Housekeeping Yes NoN/A

l. Accident/Incident Reporting Yes NoN/A

m. Unsafe Condition Reporting Yes NoN/A

n. Emergency Preparedness, including evacuation plan Yes NoN/A

o. Waste Disposal/Waste Minimization/Spill Prevention Yes NoN/A

p. Back Injury Prevention Yes NoN/A

q. Hazwoper Training Yes NoN/A

r. Heat Stress Prevention Yes NoN/A

s. Environmental Yes NoN/A

t. Scaffold Builing /Scaffold Use Yes NoN/A

u. General NDT & Radiography Yes NoN/A

Section 4: Safety, Health & Environmental Programs/Procedures

11. Do you have written programs for the following:

a. Hearing Conservation Yes NoN/A

b. Respiratory Protection Yes NoN/A

Where applicable, have employees been:

Trained Yes No

Fit tested Yes No

Medically approved Yes No

c. Hazard Communication Yes No

Have employees been trained Yes No

d. Program to support the contractor requirements of the OSHA Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents Standard (29 CFR 1910).

Yes No

e. Spill prevention and waste minimization Yes No

Section 4: Safety, Health & Environmental Programs/Procedures

12. Do you have a substance abuse program? Yes No

If yes, does it include the following?

Pre-placement Testing Yes No

Random Testing Yes No

Testing for Cause Yes No

DOT Testing Yes No

Post Incident Testing Yes No

HASAP (Houston Area Substance Abuse Program) Yes No

13. Do your employees read, write, and understand English such that they can perform their job tasks safely without an interpreter?

Yes No

If no, provide a description of your plan to assure that they can safely perform their jobs.      

Section 4: Safety, Health & Environmental Programs/Procedures

14. Medical

a. Do you conduct medical examinations for:

Pre-placement Yes NoN/A

Preplacement Job Capability Yes NoN/A

Hearing Function (Audiograms) Yes NoN/A

Pulmonary Yes NoN/A

Respiratory Yes NoN/A

b. Describe how you will provide first aid and other medical services for your employees while on-site Specify who will provide this service:

     

c. Do you have personnel trained to perform first aid and CPR? Yes No

Section 4: Safety, Health & Environmental Programs/Procedures

15. Do you hold site safety, health and environmental meetings for:

Field Supervisors Yes NoFrequency      Weekly

Employees Yes NoFrequency      Daily

New Hires Yes NoFrequency      Daily / As needed

Subcontractors Yes NoFrequency      

Are the safety, health and environmental meetings documented? Yes No

Section 4: Safety, Health & Environmental Programs/Procedures

16. Personal Protection Equipment (PPE)

a. Is applicable PPE provided for employees? Yes No

b. Do you have a program to assure that PPE is inspected and maintained? Yes No

c. Has a certified PPE assessment been completed? Yes No

17. Do you have a corrective action process for addressing individual safety, health and environmental performance deficiencies?

Yes No

Section 4: Safety, Health & Environmental Programs/Procedures

18. Equipment and Materials:

a. Do you have a system for establishing applicable health, safety, and environmental specifications for acquisition of materials and equipment?

Yes NoN/A

b. Do you conduct inspections on operating equipment e.g., cranes, forklifts, JLGs) in compliance with regulatory requirements?

Yes NoN/A

c. Do you maintain operating equipment in compliance with regulatory requirements? Yes NoN/A

d. Do you maintain the applicable inspection and maintenance certification records for operating equipment? Yes NoN/A

Section 4: Safety, Health & Environmental Programs/Procedures

19. Subcontractors

Do you use subcontractors? (If no, skip to question 43) Yes No

a. Do you use safety, health and environmental performance criteria in selection of subcontractors? Yes NoN/A

b. Do you evaluate the ability of subcontractors to comply with applicable safety, health and environmental requirements as part of the selection process?

Yes NoN/A

c. Do your subcontractors have a written safety, health and environmental program? Yes NoN/A

d. Do you include your subcontractors in:

Section 4: Safety, Health & Environmental Programs/Procedures

Safety, Health & Environmental Orientation Yes NoN/A

Safety, Health & Environmental Meeting Yes NoN/A

Safety, Health & Environmental Inspections Yes NoN/A

Safety, Health & Environmental Audits Yes NoN/A

20. Inspections and Audits

a. Do you conduct Safety, Health & Environmental inspections? Yes No

b. Do you conduct Safety, Health & Environmental program audits? Yes No

c. Are corrections of deficiencies documented? Yes No

Section 5: Information Submittal

INFORMATION SUBMITTAL

Please provide copies of checked items if applicable to your company’s work

EMR documentation from your insurance carrier Safety, Health & Environmental Training Schedule (Sample)

Insurance Certificate(s) Safety, Health & Environmental Training for Supervisors (Outline)

OSHA 200 and 300 Logs (Past 3 Years) Copy of Louisiana Contractor’s Licence

Safety, Health & Environmental Program Organization Chart

Safety, Health & Environmental Recognition ProgramList of major equipment (e.g., cranes, JLGs, forklifts) your company

has available for work at this facility.

Provide copies of checked items applicable to your company’s work.

Section 5: Information Submittal

Substance Abuse Program (Include Substances Tested & Levels)

Equipment Lockout and Tagout (LOTO)

Hazard Communication Program Confined Space Entry Program

Respiratory Protection Program Fall Protection, Scaffold use, scaffold building

Housekeeping Policy Personal Protective Equipment

Accident/Incident Investigation Procedure Portable Electric / Power Equipment

Unsafe Condition Reporting Procedure Vehicle Safety

Safety, Health & Environmental Inspection Form Compressed Gas Cylinders Program

Safety, Health & Environmental Audit Procedure or Form Electrical Equipment Grounding Assurance Program

Section 5: Information Submittal

Safety, Health & Environmental Orientation (Outline) Emergency Preparedness, including evacuation plan.

Safety, Health & Environmental Training Program (Outline) Waste Disposal Program

Example of Employee Safety, Health & Environmental Training Records

Back Injury Prevention Program

Workforce Skills Development Policies Heat Stress Prevention Program

NDT & Radiography Program Short Service New Employee Program

Brief description of your company’s “Best Practice(s)” and how they have improved your safety performance during past year.

We have implemented a program that allows our employees to only work 2 days a week but produce 5 days of production by ……………….

Who Filled Out This Information???

Need name and title of Company Officer responsible for accuracy of this document.

Overview

Fill out Contractor Information Sheet for each project site that nominated you.

Complete the Safety Awards Initial Form.Need copies of checked items applicable

to your company’s work either:• Electronic Copies (Disk)• Hard Copies• NO EMAILS! (Will not be accepted)

Overview Continued

If submitting a disk make sure:• Content is organized.• Can open all material with a common

program.• Need hard copies of Information Sheet and

Initial Evaluation Form with the disk.

Overview Continued

Please submit all Information by:• Hand delivering or,• Mailing to:

• Houston Business Roundtable 8031 Airport Blvd. Suite 118 Houston Texas, 77061

By: 4:00 PM Monday Feb 1, 2010

NO EXCEPTIONS!

Houston Business Roundtable2010 Safety Excellence Award Training