SAFETY SENSITIVE CONTRACTOR / SUPPLIER PRE-BID QUESTIONNAIRE
Scope of Work
GKN Aerospace – St. Louis is committed to providing a safe and healthy workplace for employees, contractors and
the environment. Contractors / Suppliers who have demonstrated management leadership and systems resulting
in excellent safety performance will be the only considered workforce for GKN. To help in this consideration, all
Contractors / Suppliers must first complete the following questionnaire in its entirety and return it promptly as
instructed.
Additionally, contractors seeking to qualify to perform work for GKN must:

Have a documented Environmental, Health and Safety program that meets all requirements applicable to the
work scope.

Have a company substance abuse policy and documented program.

Agree to adhere to the Substance Abuse Policy for Contractors / Suppliers at any GKN location where work is
awarded.

Agree that all subcontractors employed by the Contractor / Supplier on GKN work will also complete and
submit to GKN a suitable pre-qualification questionnaire.

Provide information/documents/records as requested to verify the Contractors / Suppliers ability to comply
with applicable GKN health and safety requirements.
Please be aware that all questions on the following pages must be completed in their entirety and will be treated
confidentially. Any unanswered question may be considered non-compliant and may be subject to disqualification
of a Contractor / Supplier to do work for GKN Aerospace – St. Louis.
MI 7.1-66(b), Rev C
Page 1 of 4
SAFETY SENSITIVE CONTRACTOR / SUPPLIER PRE-BID QUESTIONNAIRE
Scope of Work
1. Company Information:
Firm’s Legal Name:
Street Address:
City:
State:
Telephone #:
Zip:
Fax #:
Do you employ full-time safety supervision on job sites?
Does your Safety Program address all OSHA Standards as they
apply to Contractors / Suppliers?
Does your company have a Substance Abuse Program, which is
designed to provide a Drug Free Workplace?
Does your field supervision receive additional training for
Substance Abuse?
2. Insurance carrier Experience Modification Rate (EMR)
[
[
] Yes
] Yes
[
[
] No
] No
[
] Yes
[
] No
[
] Yes
[
] No
____________________________
3. Utilizing the OSHA No. 301 log for the last 3 years, the number of injuries and illnesses were recorded as
follows:
SIC Code:_________________________________
YEAR:
A. Number of hours employees worked in the
year
B. Number of restricted workday cases only
(Column 2 of OSHA 300 Log minus Column 3)
C. Number of days restricted to work
(Column 5 of OSHA 300 Log)
D. Number of cases involving lost work days
(Column 3 of OSHA 300 Log)
E. Number of days away from work (Column 4
of OSHA 300 Log)
F. Number of cases defined as Recordable but
without lost workdays (Column 6 of OSHA 300
Log)
G. Number of fatalities (Please attach full
explanation if any)
H. Total number of recordable cases (B+D+F+G)
I. Recordable Rate (H X 200,000/A) TRR
J. Lost Workday Rate [(B+D+G) X 200,000/A]
TLWR
MI 7.1-66(b), Rev C
Page 2 of 4
SAFETY SENSITIVE CONTRACTOR / SUPPLIER PRE-BID QUESTIONNAIRE
Scope of Work
4. Citations
Has your company been cited by OSHA, EPA and/or DOT in the
past 3 years?
If yes, explain:
5. Transportation:
Would you anticipate transporting chemicals to or from GKN
property during the course of work?
Yes [
[
]
] Yes
No [
[
]
] No
If yes, explain the means of transportation and qualifications to do so:
6. Legal Issues
Are there any judgments, claims or suits pending or outstanding
against your company?
Yes [
]
No [
Are now or have you ever been involved in any bankruptcy or
reorganization proceedings?
Yes [
]
No [
If yes to any of the above #6 questions, please attach details to this questionnaire.
]
]
GKN Project Manager: ________________________________________
Phone Number: (
)
________ - __________
Service Center No.:
Mobile Number: (
)
________ - __________
Estimated Start Date:
___________
Dept. No.: _________
______ / ______ / ______
Estimated Completion Date:
______ / ______ / ______
Work Location:
________________________________________________________________________________________________________
Work Description:
________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
MI 7.1-66(b), Rev C
Page 3 of 4
SAFETY SENSITIVE CONTRACTOR / SUPPLIER PRE-BID QUESTIONNAIRE
Scope of Work
Will any of the following be involved?
Will the project to be performed result in the alteration,
(check all items that apply)
removal, or demolition of: (check all items that apply)
___ Confined Space Entry
___ Known or suspect asbestos, lead, or PCB containing materials
___ Lockout / Tagout
___ Entire structure
___ Electrical Work / Live Energized Parts
___ Roofing Materials
___ Applying/Stripping Paints & Sealers
___ Sprayed-on / Troweled-on Surfacing (decorative or fireproofing)
___ Lead Work
___ Walls / Ceilings made of sheetrock, transite, or lead shielding
___ Pressure Testing
___ Painted Surfaces
___ Radiation/X-Ray/Laser Area Work
___ Thermal System / Pipe Insulation
___ Welding / Cutting
___ Ventilation Systems
___ Sprinkler / Halon System Work
___ Floor Tiles or Linoleum
___ Elevated Work / Aerial Lift / Fall Protection
___ High Voltage Cables
___ Sandblasting / Hydroblasting
___ Transformers
___ Trenching / Digging
___ Fluorescent Fixtures and/or Fluorescent/Mercury Vapor Bulbs
___ Hazardous Material / Waste Decon.
___ Tritium Exit Signs
___ Compressor Work
___ Removal of Soil / Excavation
___ Flammable / Combustible Liquids / Gases
___ Any Other Waste
___ Resurfacing / Painting / Filling
___ Respirator Use
___ Will sub-contractors be involved in project
___ Compressed Gases
Potential Physical Hazards (check all that apply)
Heat Stress
High Noise
Welding Fumes
Sand Blasting
Heavy Lifts
Acid / Caustic Fumes
High Traffic Area
Area Serviced by Cranes
Water Hazard
Flying Chips / Particles
Crushing Injuries
Uneven Work Surfaces
Falling Objects
Extreme Surface Temp.
Contact with Sharp Object
Contact with Chemicals
Comments: _______________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Receipt Verification of Authorized Company Officer:
Name
Title
Date:
FOR ESH USE ONLY
Date Received: ______ / ______ / ______
___ No Additional Safety Actions Required
___ Actions Required (give details below
___ No Additional Environmental Actions Required
___ Environmental Actions Required (give details below)
Reminder:
1. The following documents are to be submitted with
this questionnaire:
a.
List of qualified subcontractors which may
perform work on GKN property.
b. Certificate of Insurance.
c.
Additional information as needed from
questionnaire.
2. Any information submitted to GKN Aerospace - St.
Louis shall be considered GKN property upon
receipt, and held with the discretion of GKN policies
and procedures.
3. Do not submit any unrequested additional
documentation for the purpose of this questionnaire
until notification by GKN to do so. GKN holds the
right to perform any audits at the discretion of GKN.
GKN Aerospace – St. Louis holds the right to amend
and/or change this questionnaire without notice and at
the discretion of GKN personnel by management approval
only.
ESH Approval Signature: _____________________________________________________________________
MI 7.1-66(b), Rev C
Page 4 of 4