USA Contractor HSE Pre-Qualification Form
HSE-FRM-009
Rev.03/20/13
GENERAL INFORMATION
Company Name:
Telephone Number:
Fax Number:
E-mail Address:
Street Address:
Remittance Address:
Province/State:
Postal/Zip Code:
Province/State:
Postal/Zip Code:
How many years has your organization been in business under your present firm name?
Previous name of firm (if applicable):
Contact For
Name
Phone
Email
Primary
Information
Bid Purposes
HSE Purposes
ORGANIZATION
Describe Services Performed:
Construction
Construction Design
Maintenance
Personnel and Resources
Drilling
Describe Additional Services Performed:
Original Equipment Manufacturer/Installer
Original Equipment Manufacturer/Maintenance
Project Maintenance Service Work (Janitorial, Clerical, etc.)
Production
Other
List other types of work within the services you normally perform that you subcontract to others, including
brokers:
Describe any affiliations with labour organizations. (include copies of collective agreements)
Annual Dollar Volume for the Past
Three Years:
(yyyy)
(yyyy)
(yyyy)
Largest Job During the Last
Three Years:
Over $10 Million
$1 mil to $10 Million
$100,000 to $1 Million
Under $100,000
Your Firm’s Desired Project Size:
Maximum:
Minimum:
COMPANY WORK HISTORY
Major Jobs in Progress:
Customer/Location
Type of
Work
Size
$M
Customer
Contact
Telephone
Fax
USA HSE Contractor Pre-Qualification
Uncontrolled When Printed
“Road to Zero”
Page 1 of 6
Form
This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of
control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the
Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to
ensure compliance.
USA Contractor HSE Pre-Qualification Form
HSE-FRM-009
Rev.03/20/13
Major Jobs Completed in the Past Three Years:
Type of
Work
Customer/Location
Size
$M
Customer
Contact
Telephone
Fax
HEALTH , SAFETY AND ENVIRONMENT MANAGEMENT
Highest ranking HSE professional in your organization:
Name:
Telephone:
Email:
Qualifications:
CRSP
CHSC
ROH
NCSO
CSP
Trade Cert
CET
ASP
P. Eng
Other
Do you have or will you provide:
 A full-time Health, Safety and Environment representative? Yes
No
 A full-time on site Health, Safety and Environment representative? Yes
No
On site HSE representative for the duration of work.
Qualifications:
Name:
Telephone:
CRSP
CHSC
CET
ASP
Email:
ROH
NCSO
P. Eng
CSP
Trade Cert
Other
Has any employee been barred from working on any site as a Supervisor, Foreman, or Project Manager due to
Health, Safety and Environmental issues? Yes
No
HEALTH, SAFETY AND ENVIRONMENT PERFORMANCE
This Section must include all Subcontractor Injury Statistics in combination with your Company's Performance
Your Worker Compensation number:
Industry code:
From the last three years :
2009

Your Industry Premium Rate?

Your Industry Rate Adjustment %?

Surcharge or Discount?

Employers' Premium Rate?

Number of fatalities?

Number of lost time accidents? (LT)

Number of days lost?

Number of medical aid injuries? (MA)

Number of first aid injuries?
Exposure hours worked including
subcontractors
2010
2011
Field Hours
Total Hours

Total Recordable Incident Frequency? (TRIF)

Lost Time Incident Frequency?
(LTIF)
 Severity rate?
Calculation: TRIF = (# MA + # LT) x 200,000 LTIF = # LT x 200,000 Severity = LT days x 200,000
Exposure Hours (Field)
Exposure Hours (Field)
Exposure Hours (Field)
Have you been cited, charged, or prosecuted for any Occupational Health & Safety non-compliance or
Environmental Offense in the last three years? Yes
No
If Yes, give details:
USA HSE Contractor Pre-Qualification
Uncontrolled When Printed
“Road to Zero”
Page 2 of 6
Form
This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of
control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the
Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to
ensure compliance.
USA Contractor HSE Pre-Qualification Form
HSE-FRM-009
Rev.03/20/13
Has your company ever been prosecuted for an Environmental offense/issued with a stop order by or from a
Government regulatory agency? Yes
No
If Yes, give details:
Is your company capable of identifying all hazardous wastes that may be used or encountered during this
work? Yes
No
Will your company provide MSDS’ for all controlled products used on site? Yes
No
Is your company aware of the Government and legal requirements required for the disposal of any of these
Hazardous Wastes that may be encountered during this work? Yes
No
HEALTH , SAFETY AND ENVIRONMENT PROGRAM or SYSTEM AND PROCEDURES
Do you have a written Health, Safety and Environment MS/Program? Yes
No
Does the program/system address the following key elements:
 Accountabilities and responsibilities for managers, supervisors, and employees? Yes
No
 Employee participation? Yes
No
 Hazard recognition and control? Yes
No
 Management commitment and expectations? Yes
No
 Periodic Health, Safety and Environment performance appraisals for all employees? Yes
No
 Resources for meeting Health, Safety and Environment requirements? Yes
No
 Supervisor & Employee Training? Yes
No
 Safety Meetings and Communications? Yes
No
Does the program/system include Safe Operating Practices and Plans such as:
 Incident Reporting?
Yes
No
 First Aid Log Completion?
Yes
No
 Modified Work Program/Medical Accommodation Program?
Yes
No
 Compressed Gas Cylinder Handling?
Yes
No
 Confined Space Entry?
Yes
No
 Assured Grounding Program?
Yes
No
 Emergency Preparedness, including an Evacuation Plan?
Yes
No
 Equipment Lockout and Tag Out (LOTO)?
Yes
No
 Fall Protection?
Yes
No
 Housekeeping?
Yes
No
 Personal Protective Equipment (PPE)?
Yes
No
 Portable Electrical/Power Tools?
Yes
No
 Powered Industrial Vehicles (cranes, forklifts, JLGs, scissor lifts, etc.)?
Yes
No
 Unsafe Condition Reporting?
Yes
No
 Vehicle Safety? (i.e. Defensive Driving)
Yes
No
 Field Level Risk Assessment?
Yes
No
 Craning/Rigging/Lifting?
Yes
No
 Scaffolding?
Yes
No
 Hot Work and Fire Prevention?
Yes
No
Do you have written programs for the following:
 Hearing Conservation?
Yes
No
 Respiratory Protection?
Yes
No
Where applicable, have employees been:
Respirator Fit Tested?
Yes
No
Trained in use of RPE?
Yes
No
 WHMIS?
Yes
No
Do you have a Substance Abuse Policy?
Yes
No
If yes, does it include the following:
 Site Access?
Yes
No
 Pre-employment?
Yes
No
USA HSE Contractor Pre-Qualification
Uncontrolled When Printed
“Road to Zero”
Page 3 of 6
Form
This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of
control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the
Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to
ensure compliance.
USA Contractor HSE Pre-Qualification Form
HSE-FRM-009
Rev.03/20/13

Testing for Cause?
Medical:
Do you conduct medical examinations for:
 Pre-employment?
 Pulmonary function testing?
 Hearing?
 Vision?
Do you have personnel trained to perform First Aid and CPR?
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Do you hold documented site Health, Safety and Environment meetings for:
 Employees?
Yes
No
Frequency:
 Field Supervisors? Yes
No
Frequency:
 New Hires?
Yes
No
Frequency:
 Subcontractors? Yes
No
Frequency:
Personal Protection Equipment (PPE):
Is applicable PPE provided for employees? Yes
No
Do you have a program to ensure PPE is inspected and maintained? Yes
No
Do you have a corrective action process for addressing individual Health, Safety and Environment
performance deficiencies?
Yes
No
Equipment and Materials:
 Do you maintain a list of the major equipment (e.g., cranes, forklifts, JLGs) your company has
available for work at this site, and the method of establishing the competencies to operate this
equipment? Yes
No
 Do you conduct inspections on operating equipment (e.g., cranes, forklifts, JLGs, etc.) in compliance
with the regulatory requirements? Yes
No
 Do you have a system for establishing the applicable Health, Safety and Environmental specifications
for the acquisition of materials and equipment? Yes
No

Do you maintain operating equipment in compliance with manufacturer’s and local legislative
requirements? Yes
No
Do you maintain the applicable inspection and maintenance certification records for operating
equipment?
Yes
No
Subcontractors:
Do you evaluate the ability of subcontractors to comply with applicable Health, Safety and Environment
requirements as part of the selection process?
Yes
No
Do you include your subcontractors in:
 Audits?
Yes
No
 Health, Safety and Environment Meetings?
Yes
No
 Health, Safety and Environment Orientation?
Yes
No
 Inspections?
Yes
No
 Do your subcontractors have a written Health , Safety and Environment Management Program or
System? Yes
No
Do you use Health , Safety and Environment performance criteria in the selection of subcontractors?
Yes
No
HEALTH , SAFETY AND ENVIRONMENT TRAINING
Health, Safety and Environment Orientation
Program:
 Do you have a Health, Safety and
Environment Orientation for new hires and
newly hired or promoted supervisors?
 Does this process provide instruction on
the following:
New Hires
Yes
No
Supervisors
Yes
No
USA HSE Contractor Pre-Qualification
Uncontrolled When Printed
“Road to Zero”
Page 4 of 6
Form
This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of
control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the
Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to
ensure compliance.
USA Contractor HSE Pre-Qualification Form
HSE-FRM-009
Rev.03/20/13













Emergency Procedures?
Fire Protection and Prevention?
First Aid and CPR Procedures?
Incident Investigation?
Refusal to Work?
Safe Work Permits & Practices?
Personal Protective Equipment use?
Supervisors Responsibility?
Toolbox Meetings?
WHMIS Training?
Field Level Risk Assessment?
Confined Space?
How long is the orientation process?
Hours
Hours
Trade Training:
 Are employees’ job skills certified, where required, by
regulatory or industry consensus standards?
Yes
No
 Have employees been trained in the appropriate job skills?
Yes
No
 Are operators licensed and/or certified to operate the equipment used?
Yes
No
 Have your employees completed CSTS, OSHA 10 or an Industry specific equivalent?
Yes
No
List crafts which have been certified:
Health, Safety and Environment Training Program:
 Do you have a specific Health, Safety and Environment Training Program for supervisors?
Yes
No
 Do you know the regulatory Health, Safety and Environment training requirements for your
employees?
Yes
No
 Have your employees received the required Health, Safety and Environment training and retraining?
Yes
No
Training Records:
 Do you have Health, Safety and Environment and craft-specific training
records for your employees?
Yes
No
 Do the training records include the following:
o
Date of Training?
Yes
No
o
Employee Identification?
Yes
No
o
Method Used to Verify Understanding?
Yes
No
o
Name of Trainer?
Yes
No

How do you verify understanding of the training?(Check all that apply)
Job Monitoring
Oral Test
Performance Test
Written Test
Other (List)
Inspections and Audits:
Are corrections of the deficiencies documented?
Yes
No
 Do you conduct Health, Safety and Environment inspections?
Yes
No
How often?
 Do you conduct Health, Safety and Environment Management Program audits? Yes
How often?
No
USA HSE Contractor Pre-Qualification
Uncontrolled When Printed
“Road to Zero”
Page 5 of 6
Form
This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of
control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the
Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to
ensure compliance.
USA Contractor HSE Pre-Qualification Form
HSE-FRM-009
Rev.03/20/13
INFORMATION SUBMITTAL
Note: Copies of the following information must be returned in conjunction with this Form.
Records, Statements or Forms
No.
1.
Certificate of Recognition within the last three years.
2.
Worker Compensation certificate, affidavit, or letter of compliance (dated within the
last three months).
An inventory (list) of job specific work practices and procedures related to your work
activities.
A one-page sample of your safety training records.
3.
4.
5.
6.
7.
8.
9.
A one-page outline of your Employees & Supervisor Health , Safety and
Environment Training program.
A one-page outline of your employee Job Site Health, Safety and Environment
Orientation.
A one-page sample of a completed Employer's OHS First Aid Log (Names should be
blacked out).
A sample of a completed Incident Form.
10.
A sample of an employee Modified Work Form with Supervisor / Management
approval section.
A sample of a completed Hazard Assessment.
11.
A sample of a completed Field Level Risk Assessment.
12.
A sample of a completed HSE Planned Inspection Report Form.
13.
A sample of Equipment Inspection and Materials Inspection Form(s) with a
deficiency notification to client section.
A one-page schedule of your employee Health, Safety and Environment Meetings
and Scheduled Topics.
A copy of your Substance Abuse Policy.
14.
15.
16.
A one page Summary of your Company's Health, Safety and Environment
Performance Improvement.
By signing this form I certify that the attached information is correct.
Senior Contractor Representative
SIGNATURES REQUIRED
Title and Telephone Number:
Signature
Contractor HSE Representative
Telephone Number:
Signature
USA HSE Contractor Pre-Qualification
Uncontrolled When Printed
“Road to Zero”
Page 6 of 6
Form
This document is intended to be used on Graham managed projects to support the HSE MS. Anyone outside of Graham’s span of
control utilizing this document assumes all responsibility and liability arising from such use.
Graham has made every effort to ensure the accuracy of the information presented in this HSE document. Readers must refer to the
Acts, Codes, Regulations and other relevant Legislation or legal obligation applicable to your province, state or place of operations to
ensure compliance.