Community Energy | The Future of Renewable Power



PRIVATE GENERAL INFORMATIONName: FORMTEXT ????? NPRIVATE Company Name: FORMTEXT ????? Telephone: FORMTEXT ????? Fax: FORMTEXT ????? PRIVATE Street Address: FORMTEXT ????? Mailing Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Company OfficersYears With Company President: FORMTEXT ????? FORMTEXT ????? Vice President: FORMTEXT ????? FORMTEXT ????? Treasurer: FORMTEXT ????? FORMTEXT ????? PRIVATE How many years has your organization been in business under your present firm name? FORMTEXT ????? Parent Company Name: FORMTEXT ????? PRIVATE City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? PRIVATE Subsidiaries: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Under Current Management Since (Date): FORMTEXT ????? Contact for Insurance Information: FORMTEXT ????? PRIVATE Title: FORMTEXT ????? Telephone: FORMTEXT ????? Fax: FORMTEXT ????? PRIVATE Insurance Carrier(s): PRIVATE NameType of CoverageTelephone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PRIVATE 8. Are you self insured for Worker’s Compensation Insurance? Yes FORMCHECKBOX No FORMCHECKBOX PRIVATE Contact for Requesting Bids: FORMTEXT ?????PRIVATE Title: FORMTEXT ????? Telephone: FORMTEXT ????? Fax: FORMTEXT ????? PRIVATE PQF Completed By: FORMTEXT ?????PRIVATE Title: FORMTEXT ????? Telephone: FORMTEXT ????? Fax: FORMTEXT ????? PRIVATE ORGANIZATIONPRIVATE Form of Business:Sole Owner FORMCHECKBOX Partnership FORMCHECKBOX ?Corporation FORMCHECKBOX PRIVATE Percent Minority/Female Owned: FORMTEXT ?????EEO Category: FORMTEXT ?????PRIVATE A. Describe Services Performed: FORMTEXT ?????SIC Code: FORMTEXT ????? NAISC Code: FORMTEXT ????? FORMCHECKBOX Construction FORMCHECKBOX Construction Design FORMCHECKBOX Original Equipment Manufacturer and Installer FORMCHECKBOX Original Equipment Manufacturer and Maintenance FORMCHECKBOX ?Service work (e.g., janitorial, clerical, etc.) FORMCHECKBOX Project Maintenance FORMCHECKBOX Manpower and Resource FORMCHECKBOX Maintenance FORMCHECKBOX OtherB. Work CategoriesCheck the categories in which you are interested in bidding and in which you are qualified to perform work. Feel free to attach additional information clarifying your capabilities and specialities.(C) denotes work done by company employees (S) denotes work done by subcontractorsCSAir Conditioning/RefrigerationCSField Maintenance FORMCHECKBOX ? FORMCHECKBOX Comfort Cooling/HVAC FORMCHECKBOX ? FORMCHECKBOX General FORMCHECKBOX ? FORMCHECKBOX Process Refrigeration FORMCHECKBOX ? FORMCHECKBOX Hot Tap/line stops FORMCHECKBOX ? FORMCHECKBOX Leak Sealing (online)Buildings FORMCHECKBOX ? FORMCHECKBOX Field Machining FORMCHECKBOX ? FORMCHECKBOX Remodeling FORMCHECKBOX ? FORMCHECKBOX Tank/Vessel Code FORMCHECKBOX ? FORMCHECKBOX New (steel, brick, block, other) FORMCHECKBOX ? FORMCHECKBOX Boiler Code FORMCHECKBOX ? FORMCHECKBOX Exchanger RetubingCleaning FORMCHECKBOX ? FORMCHECKBOX Rotating Equipment FORMCHECKBOX ? FORMCHECKBOX Industrial FORMCHECKBOX ? FORMCHECKBOX Valve FORMCHECKBOX ? FORMCHECKBOX Janitorial FORMCHECKBOX ? FORMCHECKBOX Cooling Tower FORMCHECKBOX ? FORMCHECKBOX High Alloy Welding (list type)Civil FORMCHECKBOX ? FORMCHECKBOX Lead Lining FORMCHECKBOX ? FORMCHECKBOX Concrete FORMCHECKBOX ? FORMCHECKBOX Glass Lining FORMCHECKBOX ? FORMCHECKBOX Excavation/Grading FORMCHECKBOX ? FORMCHECKBOX Heat TreatingPaving FORMCHECKBOX ? FORMCHECKBOX Nonmetallic materials FORMCHECKBOX ? FORMCHECKBOX - Asphalt FORMCHECKBOX ? FORMCHECKBOX Pipe Fabrication FORMCHECKBOX ? FORMCHECKBOX - Concrete FORMCHECKBOX ? FORMCHECKBOX Mobil Equipment Repair FORMCHECKBOX ? FORMCHECKBOX Demolition/Dismantling FORMCHECKBOX ? FORMCHECKBOX New ConstructionElectrical FORMCHECKBOX ? FORMCHECKBOX Painting FORMCHECKBOX ? FORMCHECKBOX General FORMCHECKBOX ? FORMCHECKBOX High-voltage/High-line FORMCHECKBOX ? FORMCHECKBOX Refractory/Acid Brick FORMCHECKBOX ? FORMCHECKBOX Heat Tracing FORMCHECKBOX ? FORMCHECKBOX Cathodic Protection FORMCHECKBOX ? FORMCHECKBOX Rigging/Equipment Erection FORMCHECKBOX ? FORMCHECKBOX Grounding Systems FORMCHECKBOX ? FORMCHECKBOX ScaffoldingInspection & Testing FORMCHECKBOX ? FORMCHECKBOX General NDT FORMCHECKBOX ? FORMCHECKBOX Scale Maintenance FORMCHECKBOX ? FORMCHECKBOX Infared Scanning FORMCHECKBOX ? FORMCHECKBOX Eddy Current Testing FORMCHECKBOX ? FORMCHECKBOX Structural Steel Fab/Erection FORMCHECKBOX ? FORMCHECKBOX Acoustic Emission FORMCHECKBOX ? FORMCHECKBOX Column Scanning FORMCHECKBOX ? FORMCHECKBOX Tanks - Field Erection FORMCHECKBOX ? FORMCHECKBOX Civil/Soils FORMCHECKBOX ? FORMCHECKBOX High Voltage Electrical FORMCHECKBOX ? FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX ? FORMCHECKBOX Electrical Ground Inspection FORMCHECKBOX ? FORMCHECKBOX FORMTEXT ?????ORGANIZATION InstrumentationConsulting FORMCHECKBOX ? FORMCHECKBOX General FORMCHECKBOX ? FORMCHECKBOX - Mechanical FORMCHECKBOX ? FORMCHECKBOX DCS Control Systems FORMCHECKBOX ? FORMCHECKBOX - Electrical FORMCHECKBOX ? FORMCHECKBOX - Chemical Insulation FORMCHECKBOX ? FORMCHECKBOX - Metallurgical FORMCHECKBOX ? FORMCHECKBOX General FORMCHECKBOX ? FORMCHECKBOX - Controls FORMCHECKBOX ? FORMCHECKBOX Asbestos Abatement FORMCHECKBOX ? FORMCHECKBOX - Other FORMTEXT ????? FORMCHECKBOX ? FORMCHECKBOX FORMTEXT ????? Linings/coatings for: FORMCHECKBOX ? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX ? FORMCHECKBOX Metal FORMCHECKBOX ? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX ? FORMCHECKBOX Concrete FORMCHECKBOX ? FORMCHECKBOX FORMTEXT ?????PRIVATE 14.Describe Additional Services Performed: FORMTEXT ????? 15.List other types of work within the services you normally perform that you subcontract to others: FORMTEXT ????? 16.A. Do you normally employ? Union Personnel FORMCHECKBOX Non-Union Personnel FORMCHECKBOX Leased Personnel FORMCHECKBOX If union, list trades/locals: FORMTEXT ????? B. Average number of employees for last 3 years FORMTEXT ?????COMPANY WORK HISTORYPRIVATE 17.Annual Dollar Volume for the Past Three Years:20 FORMTEXT ??? $ FORMTEXT ????? 20 FORMTEXT ??? $ FORMTEXT ????? 20 FORMTEXT ??? $ FORMTEXT ????? PRIVATE 18.Largest Job During the Last 3 Years: $ FORMTEXT ????? PRIVATE 19.Your Firm’s Desired Project Size: FORMTEXT ????? Maximum: FORMTEXT ????? Minimum: FORMTEXT ????? 20.D&B Number: FORMTEXT ???? D&B Financial Rating: Annual Sales $ Net Worth: $ FORMTEXT ????? 21.Major jobs in progress:PRIVATE Customer/LocationType of WorkSize$MCustomer ContactTelephone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? PRIVATE 22.Major jobs completed in the past three years:PRIVATE Customer/LocationType of WorkSize$MCustomer ContactTelephone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? PRIVATE 23.Are there any judgments, claims or suits pending or outstanding against your company?If yes, please attach details.Yes ?No ?If yes, please attach details.Yes FORMCHECKBOX No FORMCHECKBOX 24.Are you now or have you ever been involved in any bankruptcy or reorganization proceedings?If yes, please attach detailsYes FORMCHECKBOX No FORMCHECKBOX If yes, please attach details.Yes ?No ?SAFETY & HEALTH PERFORMANCEPlease provide your actual injury and illness data as developed from your OSHA 300 and OSHA 300A logs, and your Experience Modification Rates (EMR) assigned by the National Council on Compensation Insurance (NCCI)for the past three calendar years. Please calculate and record each years rate, Total Number of Cases X 200,000 / Total Hours Worked = Total Recordable Case Rate. Days away(H) + Job Transfer or Restiction(I) X 200,000 / Total Hours Worked = DART Rate. Please average the three years for each including the EMR and record them on the bottom row.YearTotal Hours Worked From OSHA Form 300A(THW)Number of Cases Tranfered fromOSHA Form 300 to OSHA Form 300ATotal Recordable Case Rate(R)(G)+(H)+(I)+(J)=(X)(X)200,000 THW =RDART Rate(Days Away Restricted or Transfered)EMRDeaths(G)Days Away(H)Job Transfer / Restriction(I)Other(J)(H) + (I)=(X)(X)200,000 THW =DART3 yrs Ago20____2 yrs Ago20____1 yrs Ago20____3 yearAverageHave you received any regulatory citations in the last three years? (OSHA, EPA, DEP)If YES, please attach explanationYes FORMCHECKBOX No FORMCHECKBOX SAFETY & HEALTH MANAGEMENTHighest ranking safety/health professional in the company: FORMTEXT ????? PRIVATE Title: FORMTEXT ????? Telephone: FORMTEXT ????? Do you have or provide:Full time Site Safety/Health Supervisor or Coordinator?Yes FORMCHECKBOX No FORMCHECKBOX Do you have or provide:Safety/Health incentive programYes FORMCHECKBOX No FORMCHECKBOX Company paid safety/health trainingYes FORMCHECKBOX No FORMCHECKBOX SAFETY & HEALTH PROGRAMS & PROCEDURESDo you have a written Safety and Health Program?Yes FORMCHECKBOX No FORMCHECKBOX Does the program address the following key elements?Management commitment and expectationsYes FORMCHECKBOX No FORMCHECKBOX Observational safety program (DuPont STOP or similar)Yes FORMCHECKBOX No FORMCHECKBOX Written Accountabilities and responsibilities for managers, supervisors, and employeesYes FORMCHECKBOX No FORMCHECKBOX Periodic safety and health performance appraisals for all employeesYes FORMCHECKBOX No FORMCHECKBOX Safety Recognition ProgramYes FORMCHECKBOX No FORMCHECKBOX Hazard recognition and control (JSA / Tailboard?) Yes FORMCHECKBOX No FORMCHECKBOX Does the program satisfy your responsibility under the law for:Ensuring your employees follow the safety rules of the facility?Yes FORMCHECKBOX No FORMCHECKBOX Advising owner of any unique hazards presented by the contractor’s work, and of any hazards found by the contractor?Yes FORMCHECKBOX No FORMCHECKBOX Does the program include work practices and procedures such as:Equipment Lockout and Tagout (LOTO)Yes FORMCHECKBOX No FORMCHECKBOX Hearing ConservationYes FORMCHECKBOX No FORMCHECKBOX Respiratory Protection - if yes, have employees been:Yes FORMCHECKBOX No FORMCHECKBOX Medically ClearedYes FORMCHECKBOX No FORMCHECKBOX TrainedYes FORMCHECKBOX No FORMCHECKBOX Fit-TestedYes FORMCHECKBOX No FORMCHECKBOX Confined Space EntryYes FORMCHECKBOX No FORMCHECKBOX Hazard CommunicationYes FORMCHECKBOX No FORMCHECKBOX Injury & Incident ReportingYes FORMCHECKBOX No FORMCHECKBOX Fall ProtectionYes FORMCHECKBOX No FORMCHECKBOX Personal Protective EquipmentYes FORMCHECKBOX No FORMCHECKBOX HousekeepingYes FORMCHECKBOX No FORMCHECKBOX Emegency Preparedness/ResponseYes FORMCHECKBOX No FORMCHECKBOX Do you have a substance abuse program? (If yes, does it include the following?)Yes FORMCHECKBOX No FORMCHECKBOX Pre-placement TestingYes FORMCHECKBOX No FORMCHECKBOX Random TestingYes FORMCHECKBOX No FORMCHECKBOX Testing for CauseYes FORMCHECKBOX No FORMCHECKBOX DOT TestingYes FORMCHECKBOX No FORMCHECKBOX Do your employees read, write, and understand English such that they can perform their job tasks safely without an interpreter?Yes FORMCHECKBOX No FORMCHECKBOX Describe how you will provide first aid and other medical services for your employees while on-site. Specify who will provide this service: Do you have personnel trained to perform first aid and CPR?Yes FORMCHECKBOX No FORMCHECKBOX SAFETY & HEALTH PROGRAMS & PROCEDURESDo you hold site safety and health meetings for:Field SupervisorsYes FORMCHECKBOX No FORMCHECKBOX Frequency?EmployeesYes FORMCHECKBOX No FORMCHECKBOX Frequency?New HiresYes FORMCHECKBOX No FORMCHECKBOX Frequency?SubcontractorsYes FORMCHECKBOX No FORMCHECKBOX Frequency?Are the safety and health meetings documented?Yes FORMCHECKBOX No FORMCHECKBOX Personal Protection Equipment (PPE)Is applicable PPE provided for employees?Do you have a program to assure that PPE is inspected and maintained?Yes FORMCHECKBOX No FORMCHECKBOX Equipment and Materials:Do you conduct inspections on operating equipment (e.g., cranes, forklifts, JLGs) in compliance with regulatory requirements?Yes FORMCHECKBOX No FORMCHECKBOX Do you maintain the applicable inspection and maintenance certification records for operating equipment?Yes FORMCHECKBOX No FORMCHECKBOX Subcontractors:Do you use subcontractors? Yes FORMCHECKBOX No FORMCHECKBOX Do you use safety and health performance criteria in selection of subcontractors?Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Do you evaluate the ability of subcontractors to comply with applicable health and safety requirements as part of the selection process?Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Do your subcontractors have a written Safety & Health Program?Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Do you include your subcontractors in:Safety & Health OrientationYes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Safety & Health MeetingYes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX AuditsYes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Inspections and AuditsDo you conduct routine safety and health inspections?Yes FORMCHECKBOX No FORMCHECKBOX Are corrections of identified deficiencies documented?Yes FORMCHECKBOX No FORMCHECKBOX Do you have a corrective action process for addressing deficiencies:Yes FORMCHECKBOX No FORMCHECKBOX SAFETY & HEALTH TRAININGSafety & Health OrientationNew HiresSupervisorsDo you have a Safety & Health Orientation Program for new hires and newly hired or promoted supervisors?Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Does program provide instruction on the following:New Worker OrientationYes FORMCHECKBOX No FORMCHECKBOX Safety SupervisionYes FORMCHECKBOX No FORMCHECKBOX Conducting TailboardsYes FORMCHECKBOX No FORMCHECKBOX SAFETY & HEALTH TRAININGEmergency ProceduresYes FORMCHECKBOX No FORMCHECKBOX First Aid ProceduresYes FORMCHECKBOX No FORMCHECKBOX Incident Reporting & InvestigationsYes FORMCHECKBOX No FORMCHECKBOX Fire Protection and PreventionYes FORMCHECKBOX No FORMCHECKBOX Hazard CommunicationYes FORMCHECKBOX No FORMCHECKBOX How do you verify comprehension? (Written test, Craft Test, Performance Test, Job Monitoring, Other?)Safety & Health TrainingDo you have a specific safety and health training program for supervisors?Yes FORMCHECKBOX No FORMCHECKBOX Are all employees trained in the work practices needed to safely perform his/her job?Yes FORMCHECKBOX No FORMCHECKBOX PRIVATE INFORMATION SUBMITTAL Please provide copies of checked items with the completed PQF:XEMR documentation from your insurance carrier (Include Past 3 Years)XInsurance Certificate(s)XOSHA 300 and 300A Logs (Include Past 3 Years)X NAICS Number Prefered, SIC Number Minimum (See page 2)XSafety & Health Program, Safety & Health Manual FORMCHECKBOX Safety & Health Incentive Program FORMCHECKBOX Substance Abuse Program (Include Substances Tested & Levels) FORMCHECKBOX Hazard Communication Program FORMCHECKBOX Respiratory Protection Program FORMCHECKBOX Housekeeping Policy FORMCHECKBOX Accident/Incident Investigation Procedure FORMCHECKBOX Unsafe Condition Reporting Procedure FORMCHECKBOX Safety & Health Inspection Form FORMCHECKBOX Safety & Health Audit Procedure or Form FORMCHECKBOX Safety & Health Orientation (Outline) FORMCHECKBOX Safety & Health Training Program (Outline) FORMCHECKBOX Example of Employee Safety & Health Training Records FORMCHECKBOX Safety & Health Training Schedule (Sample) FORMCHECKBOX Safety & Health Training for Supervisors (Outline) Attach a list of major equipment (e.g., cranes, JLGs, forklifts) your company has available for work at this facility and the method of establishing competency to operate.Note:Owner checks items to be provided with PQF.This document must be signed by a company officer. ___________________________________ ___________________________ __________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TitleNameDatePQF EVALUATION -- OWNER USE ONLY –Required reviewers will be determined by the Procurement Group FORMCHECKBOX Required Reviewers:AcceptableMarginally AcceptableUnacceptable FORMCHECKBOX Safety & Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Procurement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Credit FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NOTES: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download