Procedure Number:
SCHNEIDER ELECTRIC
North American Division
Safety, Health and Environmental Procedures
PAGE 1 OF 25
DATE EFFECTIVE:
NAME:
SUPERSEDES:
Contractor Safety & Environmental Procedure
Approval
PURPOSE: To ensure Contractors perform work on our sites
without posing a threat to their Safety or the Safety of
our employees. They will also take all necessary
measures to ensure the protection of human health and
the environment. Safety and Environmental
performance is a consideration in the Contractor
administration and selection process.
ISSUED BY:
Corporate
ATTACHMENTS
Attachment A
Attachment B
Attachment C
Attachment D
Attachment E
Attachment F
Attachment G
Attachment H
Attachment I
Attachment J
1.
DEPT:
SH&E
New
Initials
DISTRIBUTION:
Date
Approval
Initials
Non-Limited
Additional Site Requirements
Contractor Approval Checklist
Contractor Safety Information Data Sheet
Contractor Orientation Checklist
Contractor Site Safety Representative
Sample – Letter of Approval
Contractor Job Site Safety Checklist
Contractor Safety Report
Contractor Safety Program Training Log
Contractor Hold Harmless Agreement
SCOPE
This policy applies to Schneider Electric North American Division and its subsidiaries and
affiliates in North America (referred to collectively in this policy as “Schneider Electric”).
Schneider Electric has prepared this Contractor Safety & Environmental Program to provide
specific guidelines for determining the suitability of service providers relative to safety, health
and environmental (SH&E) performance. This program applies to the following specific service
providers:




Equipment installation or repair companies
Electrical Services Companies
Rigging/Crane Companies
Building construction or repair companies

HVAC service and repair

Mechanical and Plumbing installation and repair

Food service organizations

Custodial service companies
Date
2

Any other contractor or subcontractor used on site
Service providers contracted directly to Schneider Electric are evaluated and selected using the
guidelines established in this Program. Each contractor utilized by Schneider Electric is
evaluated to determine adherence to the intent and compliance with the requirements of this
program. Contractor personnel at the site must comply with all applicable SH&E regulations and
Schneider Electric’s SH&E policies and procedures.
2.
PROCEDURE
This section describes the process for bidding and performing work for Schneider Electric.
Service providers (as listed in the Scope) that will perform work on our site are subject to the
requirements detailed in this section. The process of managing the Contractor Safety &
Environmental Procedure is divided into three steps: A. Approval, B. Orientation, and C.
Training, followed by audits. Each of these steps is described below.
A. Safety & Environmental Approval of Contractors
Each Contractor is reviewed and approved before being allowed to bid work that will be
contracted directly to Schneider Electric. Approval consists of the following steps:
1) Each prospective Contractor is provided a copy of the Contractor Safety & Environmental
Program and instructed to complete and submit the following:

Contractor Approval Checklist (Attachment B)

Contractor Safety Information Data Sheet (Attachment C)

Contractor Site Safety Representative (Attachment D)
2) The Contractor completes the required forms and submits these along with a copy of any
specific written safety programs that will be used as part of the work (i.e., hazard
communication, lockout/tagout, confined spaces, etc.)
3) The Schneider Electric representative (Safety & Environmental Mgr., Plant Engineer,
Project Supervisor, etc.) reviews each Contractor’s submittal to determine if the company
meets the minimum criteria for approval. Approval is based on the following:
 Workers’ Compensation Experience Modification Rating (EMR) of 1.0 or less.
 OSHA Recordable of less than 10.0 and Lost Time Accident frequency rates less than
3.0.
 Hold Harmless Agreement from Contractor. (Attachment J)
 Certificates of Insurance for WC, Auto, and General Liability (Attachment J)
 Contractor Safety Programs contain the following:
Safety & Environmental Policy
Environmental Awareness (General)
Hazard Communication/WHMIS
Safety Rule Enforcement
Employee Rights & Responsibilities
Housekeeping
Employee Access to EmployeeInfectious Control
3
Exposure and Medical Records
Machine Guarding
Material Handling (Manual Lifting)
Driving Safety
Electrical Safety
Emergency Procedures
Ergonomics
Accident Reporting & Investigation
Alcohol and Drug policy
Unsafe Act/Condition Reporting
Parking Lot Safety
Personal Protective Equipment
Fall Prevention
Lockout/Tagout
Where applicable, the programs should also include:
Confined Spaces
Hearing Conservation
Respiratory Protection
Industrial Truck Operations
Electrical Safety Work-Related Practices
 For Contractors renewing approval, review of completed Contractor Job Site Safety
Checklist forms indicates positive findings during previous work.
 Compliance with any additional site-specific SH&E requirements (Attachment A).
 Understanding that all jobs bid will include an on-site supervisor.
 Contractor will supply all necessary tools and equipment for the job. Schneider
Electric tools and equipment will not be used by the contractor except in an
emergency situation where human life is in danger.
4) Following the review, the Schneider Electric representative notifies the Contractor
regarding the result of the approval process using the Letter of Approval form
(Attachment F).
5) Each Contractor must renew approval at the beginning of each calendar year. With each
bid, the Contractor submits a copy of the Letter of Approval (to verify prior approval) and
an updated Contractor Site Safety Representative (Attachment E) form. When approval
expires, the process outlined above is repeated.
B. Contractor Orientation
1) Prior to beginning work, the Contractor Site Safety Representative receives an orientation
briefing from the Schneider Electric representative regarding requirements for working at
the site. This briefing would include the following:
 Emergency Contact Information
 All work on site requires the contractor to provide an on-site supervisor.
 All work performed on-site will be with contractor’s tools and equipment. Schneider
Electric tools and equipment will not be used.
 Site Smoking Policy
 Site Housekeeping Requirements
 Parking and Site Access Restrictions
 Schneider Electric’s Safety &Environmental Rules and Practices (Location SH&E
Handbook)
4
 Overview of the plant Environment policy including management of all generated
wastes.
 Overview of Zero Tolerance Policy regarding harassment and use of alcohol and/or
drugs
 Emergency response information (alarm signals, location of shelter areas, etc.)
 Notification requirements regarding accidents, incidents and near misses
 Requirements regarding use of chemicals at the site and means of obtaining a Material
Safety Data Sheet.
 Required Personal Protective Equipment (PPE) while on the site
 Required permits for performing the work and means of obtaining permits, i.e. hot
work permit.
 Use of ladders, scaffolding or rigging.
 Fall protection policy at heights of 6 feet or higher.
 Requirements regarding lockout/tagout
 Electrical safety requirements, including no live work and appropriate PPE.
 Location and hazards of confined spaces in the vicinity of the work area(s)
 Use of electrical equipment and Ground Fault Circuit Interrupters (GFCI)
 If there are any hazardous materials, i.e. PCBs or ACM’s, or noise control areas in the
building.
Site-specific requirements regarding these items are outlined on the attached Contractor
Orientation Checklist (Attachment D). The Contractor’s Site Safety Representative is
responsible for training all onsite Contractor personnel in these and other site-specific
requirements.
2) Contract Administration
Once work has begun, the onsite activity of each Contractor performing work for
Schneider Electric is periodically reviewed to document compliance with provisions of
the safety program. The Schneider Electric representative performs this review using the
Contractor Job Site Safety Checklist (Attachment G). These reviews are performed
according to the schedule presented below.
Project Duration
Review Schedule
Up to one day

Immediately prior to the conclusion of the work
Up to one week

At least once during the work

At the conclusion of the work

At least twice during the first week of work

At least once per additional week of work
More than one week
5
Ongoing

At the conclusion of the work

At least once per month
For work that lasts one week or more, the Contractor must submit a report of onsite
activities to the Schneider Electric representative using the Contractor Safety Report form
(Attachment H).
The results of each review are communicated to the Contractor Site Safety Representative
for corrective action. Results of these reviews are considered when determining whether
to renew or maintain approval for the Contractor.
3) Withdrawing Approval for a Contractor
Schneider Electric reserves the right to terminate any approved Contractor for failure to
comply with site rules and regulations and/or to correct unsafe conditions or practices.
Schneider Electric reserves the right to remove any approved Contractor from the
“Approved Contractor List” for failure to comply with established safety rules and
regulations or for allowing an unsafe condition to exist in the workplace. Upon correction
of the deficiency, the Contractor’s name may be reinstated on the “Approved Contractor
List.” Additionally, Schneider Electric reserves the right to terminate any agreement
according to the terms and conditions of such agreement.
C. Training
The Schneider Electric Representative, during a Toolbox meeting, will communicate to
Schneider Electric employees the requirements of the Contractor Safety &Environmental
Program as well as any potential hazards introduced to their work area by the Contractor.
Employees who are involved in the evaluation process must be knowledgeable regarding the
specific work that is to be performed. For example, employees who are qualified under the
electrical safe work practices would review Contractor electrical safety programs.
Employees who perform reviews of the Contractor’s onsite activities shall be trained to
recognize hazardous conditions and to complete the Contractor Job Site Safety Checklist
(Attachment G).
All training shall be documented using the Contractor Safety Program Training Log
(Attachment I).
3.
DEFINITIONS
A. Contractor: A business that is in contract with Schneider Electric to perform a service or
provide a product.
B. Experience Modification Rate (EMR): An evaluation of a company’s last three full years of
workers’ compensation losses based upon payroll amount and their Standard Industrial
6
Classification (SIC) Code. This evaluation compares the anticipated losses for a particular
firm versus the actual losses experienced by the firm. An EMR of 1.0 means that actual
losses were equal to anticipated losses.
C. Hazardous Conditions: Any existing or potential condition in the workplace, which, by
itself or by interacting with other variables, can result in deaths, injuries, property damage, or
other losses.
D. Lost-Time Accident Frequency Rate: The number of lost workday cases per 100
employees. These cases include recordable injuries that involve days away from work. To
determine the frequency rate, multiply the total number of cases by 200,000 and divide the
answer by the total employee hours worked.
E. OSHA Recordable Injury Frequency Rate: The number of OSHA recordable injuries per
100 employees. These injuries include all work-related deaths and illnesses and those workrelated injuries that result in loss of consciousness, restriction of work or motion, transfer to
another job, or medical treatment beyond first aid. To determine the frequency rate, multiply
the total number of recordable cases by 200,000 and divide the answer by the total employee
hours worked.
F. SIC (Standard Industrial Classification) Code: Classification system used by the Bureau
of Labor Statistics, which groups business operations under a two, three or four-digit code.
The Bureau associates vital statistics with each defined code. Injury rates compiled by the
Bureau and associated with particular industries are used as baselines for determining
performance against similar workplaces.
4.
RESPONSIBILITIES
A. Location Plant Engineer

Maintains a current list of approved Contractors for use at his/her account locations

Authorizes, in consultation with SH&E, approval of any Contractor failing to meet the
minimum valuation criteria as outlined in this Program.
Administers the written Contractor Safety Program.
Requires evaluation of all Contractors submitting bids for work.


B. Schneider Electric Representative (Usually the SH&E Manager)

Ensures that Schneider Electric employees are trained and aware of potential hazards
introduced to their work area by the Contractor (Documented in Toolbox meeting).

Ensures that all Schneider Electric employees understand and comply with the requirements
of this Program.

Identifies Contractors whose work on-site could impact the environment and/or health and
safety of employees at the site.

Provides or arranges a site orientation briefing for the Contractor Site Safety Representative
regarding environmental health & safety requirements specific to the location and the
Contract (Attachment D).
7

Informs Contractor Site Safety Representative of presence of toxic or hazardous chemicals
and provides Material Safety Data Sheets (MSDS) as requested.

Coordinates appropriate safety procedures, e.g. lockout/tagout, hot work permits, access to
restricted areas, etc. with Contractor Site Safety Representative.

Performs general review of Contractor activities to document adherence with applicable
SH&E requirements (Attachment F). All noted deviations from site requirements by
Contractor personnel are reported directly to Contractor Site Safety Representative for
correction.

Maintains copies of all documentation submitted by each Contractor related to approval,
orientation and review of onsite work
C. Buyers

Use only approved Contractors from updated list.

Assist with identification of prospective Contractors for performing work at the site.
D. Employees

Notify immediate supervisor of any Contractor employee action that has or may result in a
hazardous condition or behavior.
E. Contractors

Designate a “Contractor Site Safety Representative” who has responsibility and authority
for ensuring compliance with the requirements of this Program.

Comply with current federal Safety and Environmental regulations and all applicable state
and local laws, codes, rules, regulations or ordinances governing the work.

Ensure that all Contractor employees comply with applicable site SH&E requirements.

Ensure Contractor provides all necessary and appropriate tools and equipment, including
personal protective equipment, required for safe completion of required tasks.

Utilize a workforce that is appropriately trained in all SH&E aspects of the job.

Provide documentation of employee training, as requested.

Maintain all equipment, tools and work areas in a clean and safe manner.

Obtain necessary permits for performing the work.

Provide for onsite first aid and emergency medical services.

Notify Schneider Electric’s Representative of any injury, incident or near miss involving
Contractor employees while at the project location.

Perform inspection of work activities and areas for compliance with SH&E standards and
procedures.
8
5.

Inform Schneider Electric of any subcontractors to be used as part of the work and ensure
these subcontractors comply with all SH&E requirements.

Provide a copy of the Contractor Safety Report (Attachment H) weekly and/or monthly
according to the requirements of Schneider Electric.

Ensure that no Contractor activities endanger other personnel working at the site.

Participate in all evacuation drills.

Accept that failure to comply with SH&E requirements, including failure to correct unsafe
practices and conditions, are sufficient grounds for Schneider Electric to require work
stoppage or termination of the contract agreement.
AUTHORITY
A. The Plant Engineer or Project Manager has the authority to implement this procedure and to
review and audit the implementation of this procedure.
B. The SH&E Manager has the authority to update and audit this procedure.
9
Attachment A
Date:
ADDITIONAL SITE REQUIREMENTS
This attachment outlines SH&E evaluation and approval requirements which are in addition to those
presented in the Schneider Electric Contractor Safety Program. These requirements include:
(List or Attach Additional SH&E Approval Criteria)
Example: Additional requirement for electrical subcontractors:
Fire retardant PPE, CAT III measurement equipment, voltage rated gloves, 4/0 grounding cable with
permanent connections, GFI in use
Evaluation, orientation and review additional service providers subject to these requirements:
10
Attachment B
Date:
CONTRACTOR APPROVAL CHECKLIST
1. Has Schneider Electric’s Contractor Safety Information Data Sheet been
completed?
2. Are all applicable Licenses / Permits completed and on file? (Attach copies)
3. Have all affected employees received appropriate training, including Hazard
Communication Training as required by OSHA 29 CFR 1910.1200 or
WHMIS?
4. Have any Safety or Environmental regulatory citations been issued to this
company in the last 3 years? (If yes, attach a summary describing the
inspection and resultant citation.)
5. Does this company have a mandatory substance abuse program?
 Pre-employment Screening?
 Random Testing?
 Testing for Cause?
6. Is there a light duty / restricted work policy?
7. Do all new employees complete Safety & Environmental Orientation prior to
performing any work activities?
8. Are routine safety inspections conducted?
9. Are safety and environmental program audits routinely conducted?
10. Are on-site “toolbox” safety meetings routinely conducted?
11. Are accident investigations conducted and documented?
12. Does this company employ a Safety Coordinator, Safety Supervisor, or
Director of Environmental, Health & Safety? (Please circle all that apply.)
13. Is a Safety / Health incentive program provided?
14. Is there a written Environmental, Health & Safety Program?
15. Does the program address the following key elements:
 Management commitment and expectations?
 Employee participation?
 Accountability / responsibility for managers, supervisors and employees?
 Resources for meeting safety and health requirements?
Yes
No
N/A
11
Attachment B (cont.)
Date:
CONTRACTOR APPROVAL CHECKLIST
Yes
No
 Periodic safety and health performance appraisals for all employees?
 Hazard recognition and control?
 A Confined Space Entry Program?
 A “Hot Work” Permitting Program?
 A Hazardous Energy Lockout / Tagout Program?
 A Medical Surveillance Program?
 A Personal Protective Equipment Program?
 A Respiratory Protection Program?
 A Fall Protection Program with employees tied off at 6ft. or higher?
 Worker Exposure Monitoring Program?
 A Powered Industrial Vehicle Program (Cranes, forklifts, JLGs, etc.)?
 A Housekeeping Program?
 An Emergency Preparedness & Evacuation Program?
 A Waste Disposal Program?
 A Fire Protection and Prevention Program?
 A Recordkeeping Program (Training, inspections, audits, etc.)?

An Electrical Safety Program with “No Live Work Policy”?

A Tool and Equipment Inspection Program?



Do employees read, write and understand English such that they can perform their job
tasks safely without an interpreter?
____________________________________
Signature of Contractor
Representative
____________________________________
Signature of Contractor Safety Site
____________________________________
Phone Number
____________________________________
Contact Phone Number
N/A
12
Attachment C
Date:
CONTRACTOR SAFETY INFORMATION DATA SHEET
Name of Vendor: ______________________________
Man-hours Worked (for past three years): __________
Total OSHA Recordable Rate (for past three years):
Rate = (Total Recordable Injuries) x 200,000/
Total Employee Hours
SIC Code: __________
____________
_____________
_______________
Rate
_______________
Rate
_______________
Rate
__________
Year
__________
Year
__________
Year
_______________
Rate
_______________
Rate
_______________
Rate
__________
Year
__________
Year
__________
Year
_______________
Number
_______________
Number
______________
Number
__________
Year
__________
Year
__________
Year
Industrial average: __________ Year: __________
Lost Time Accident Rate (for past three years):
Rate = (Total Lost Time Accidents) x 200,000/
Total Employee Hours worked
Industrial average: __________ Year: __________
Number of Fatalities(for past three years):
Industrial average: _________
Year: _________
__________________________________________
Signature of Contractor Safety Representative
_____________
Date
13
Attachment D
Date:
CONTRACTOR ORIENTATION CHECKLIST
 Completed
1.0 Emergency Contact Information
Schneider Electric/Customer Resources:
Schneider Electric Project Manager
Contractor’s Safety Coordinator
Schneider Electric’s Facility Engineer
External Resources
Police/ Fire Department
Local Medical Facilities
Security
HAZMAT Response Team
Office #
Pager #
Office #
911 or 9-911
Pager #
 Completed
2.0 Site Smoking Policy
___ Smoking is not permitted anywhere at this site.
___ Smoking is permitted ONLY in the following areas:
3.0 Parking and Site Access Restrictions
 Completed
Contractor employees are restricted from parking personal vehicles on site unless authorized by a Site
Representative. Parking is available at __________________________________________________.
(This is /is not a secure lot that is patrolled regularly by site security.)
Shuttle/bus service is available from the hours of ___:___ AM/PM to ___:___ AM/PM.
Parking on-site is limited. If driving a company vehicle, arrangements for parking on site must be made
with a Site Representative.

Speed Limit --- __________mph

Sit only in seats that are provided and have seatbelts

Yield to pedestrians approaching the service roads

Come to a complete stop at Stop signs.

Park only in approved, designated parking spots as authorized by the Site Representative
14
Attachment D (cont.)
Date:
CONTRACTOR ORIENTATION CHECKLIST
 Completed
4.0 Site Housekeeping Requirements
It is the responsibility of the Contractor employees to maintain a clean and orderly work area to
minimize fire and fall hazards. It has been proven through OSHA statistics that poor housekeeping
leads to slips, trips, and falls on construction sites. Therefore, when contracted work has been
completed or at the end of the work day/shift, Contractor ensures that the area is clean.
Employees shall immediately notify their Supervisor of any perceived fire or fall hazards.
Clear access shall always be maintained in Contractor working areas to electrical panels, fire
extinguishers, safety showers and eyewash stations, and fire hydrants. Non-compliance with this policy
may impede the response time of emergency responders and cause unnecessary delays in the event
of an emergency.
5.0 Schneider Electric’s Safety & Environmental Rules and Practices (Location
SH&E Booklet)
 Completed
A copy of this document may be obtained from the Schneider Electric
representative.
6.0 Overview of Zero Tolerance Policy regarding Sexual Harassment and
Discriminatory Behavior
 Completed
Schneider Electric has a ZERO TOLERANCE policy for both sexual harassment and discriminatory
behavior. Unprofessional behavior that creates a hostile work environment for individuals with regard
to Age, Race, Religion, Physical Disabilities, or Sexual Orientation will not be tolerated.
Both types of behavior are very subjective and difficult to defend against. If a complaint is registered,
by law Schneider Electric will pursue that complaint to the extent that the law requires.
Violators will be removed from the site.
7.0 Overview of Zero Tolerance Policy regarding Alcohol and Drug Use
 Completed
Employees and visitors shall not report to work at the site under the influence of any substance that
may affect their ability to safely perform their work, operate equipment, make conscientious decisions,
or that may in any way jeopardize the health and safety of other employees.
If there is reason to believe that someone is under the influence of such a substance, that person may
be asked to submit to drug testing or leave the site. If a controlled or illegal substance is suspected,
the proper authorities will be contacted.
Illegal substances shall not be brought to the site. Anyone taking prescribed medication and/or who is
under the care of a doctor shall notify their immediate supervisor who will then tailor their work
assignment accordingly.
8.0 Emergency response information (alarm signals, shelter areas, etc.)
A copy of this document may be obtained from the Site Representative.
9.0 Notification requirements regarding accidents, incidents and near misses
A copy of this document may be obtained from the Site Representative.
10.0 Requirements regarding the use of chemicals at the site and means of
obtaining a Material Safety Data Sheet.
A copy of this document may be obtained from the Site Representative.
 Completed
 Completed
 Completed
15
Attachment D (cont.)
Date:
CONTRACTOR ORIENTATION CHECKLIST
11.0 Required Personal Protective Equipment (PPE) while on the site
 Completed
Contractors are responsible for providing their employees with proper Personal Protective Equipment
(PPE) to protect them while they are working and must train them in the proper inspection,
maintenance, and safe use of that equipment. Contractors are responsible for conducting job
assessment to determine the proper PPE necessary for each job.
At a minimum, construction employees are expected to wear hard hats and appropriate work boots,
plus ANSI Z-87-approved safety glasses with safety frames and side shields at all times. Additionally,
harnesses, respirators, gloves, face shields, and hearing protection are typically required in most
construction zones. In plant areas, steel-toed shoes are required, and strongly recommended in
construction areas.
Fall Protection

100% tie-off

6’ tie-off required in all circumstances (Steel Erection, Scaffold Erection, etc.)

5,000 lb. Anchorage required

Employees must be trained in proper inspection, maintenance and safe use of equipment.
Respirators

Require written program

Medical approval for all employees utilizing respirators

Training
Hearing Conservation

If the work area is above 90dB on the TWA, a written program and hearing protection is required.
12.0 Required permits for performing the work and means of obtaining permits
 Completed
_____ Hot Work Permit
Anything that generates heat, flame or spark, OR any electrical hot work (Live electrical panels or
circuits) requires a hot work permit. An appropriate Fire Extinguisher, dedicated trained fire watch
person (who understands elements, stages, and causes of fire, etc.), and an evaluation of
explosive/flammable atmospheres is necessary.
_____ Confined Space Entry Permit
This requires a site-specific program. All companies conducting confined space entries must submit a
written program and documented evidence that their employees have been adequately trained in their
duties and hazards associated with their work. Contractors must provide their own calibrated monitors
and rescue equipment.
_____ Lockout/Tagout Permit
This requires a site-specific program. Contractors must coordinate their Lockout/Tagout procedures
with those existing on-site. Once affected circuits, piping, dissipated hazardous energy, switches,
valves and/or other processes have been identified by the Customer and/or Schneider Electric,
contractor personnel shall place their own lock on the Customer’s lock to ensure against accidental
start-up.
16
Attachment D (cont.)
Date:
CONTRACTOR ORIENTATION CHECKLIST
 Completed
13.0 Use of ladders, scaffolding or rigging
_____ Ladders
See Fall Protection Procedure for ladder and scaffolding safety.
_____ Scaffolding
All cross braces and handrails must be installed. A competent person is required for scaffold erection
and inspection. Scaffolding is to be inspected daily by a competent person and the inspection tags
signed. Tagging systems are site-specific.
_____ Rigging
All rigging must have a legible load tag and must be inspected before each pick. Riggers shall be
designated as competent persons. Chains are not allowed except for use with a chain fall. Only
synthetic or wire rope slings are allowed.
Information regarding Other Permits as required by site and the means for obtaining these permits is
available from the Site Representative.
14.0 Requirements regarding lockout/tagout.
A copy of this document may be obtained from the Site Representative.
15.0 Location and hazards of confined spaces in the vicinity of the work area(s)
A copy of this document may be obtained from the Site Representative.
 Completed
 Completed
16.0 Use of electrical equipment and Ground Fault Circuit Interrupters (GFCI)
All electrical equipment must be connected to a GFCI. Tools shall be regularly
inspected for defects (cuts, exposed insulation, missing ground pin, etc.). Tools
with damaged cords or plugs shall be removed from service immediately.
 Completed
Other Site Specific Requirements
 Completed
 Completed
 Completed
 Completed
 Completed
______________________________
_____________________________
Signature of Contractor
Signature of Contractor Site Safety
Representative
____________________________________
Phone Number
____________________________________
Contact Phone Number
17
Attachment E
Date:
CONTRACTOR SITE SAFETY REPRESENTATIVE
Name of Contractor:
Project Identification:
The following named person is the Contractor Site Safety Representative for the above referenced contract.
He/she is capable of identifying existing and predictable hazards in the surroundings or working conditions that
are unsanitary, hazardous, or dangerous to employees. In addition, this employee is the contact person between
Schneider Electric and ________________________________________ (insert name of Contractor), in the event
that Schneider Electric personnel observe any unsafe condition, practice, etc.
Name of Contractor Site
Safety Representative: ________________________________________
Appointed by: _______________________________________________
Title: ______________________________________________________
Signature: __________________________________________________
Date: ______________________________
Submit this form with each bid.
18
Attachment F
Date:
SAMPLE – LETTER OF APPROVAL
(Date)
Contractors Name
Address 1
Address 2
City, State - Zip Code
Dear
:
Thank you for submitting application for approval to work for Schneider Electric.
Our review indicates that your past safety performance, based on OSHA frequency rates
and experience modification rate (EMR), meets (does not meet) our criteria for approval.
Reviews of Environmental, Health & Safety (HAZCOM, Bloodborne, etc.) programs
submitted by your firm indicate that they are acceptable (not acceptable).
This letter is valid through the end of the calendar year. Should your firm demonstrate
non-compliance to established site safety rules and regulations, revocation of approval
status may result.
During this period, you are approved to submit bids for and perform contract work at the
Schneider Electric Site located at: (Location). You need only to attach a copy of this
letter to your bid.
Thank you for committing to “Working together – SAFELY.”
Sincerely,
Schneider Electric
Name
Title
19
Attachment G
Date:
CONTRACTOR JOB SITE SAFETY CHECKLIST
Contractor:
________________________________________
Date: ___________________
Job Location: ________________________________________
Project Title: _________________________________________
Evaluated by: _________________________________________
Some of the questions in the checklist may not apply to all job sites; conversely, additional questions may be
necessary.
Category
Acceptable
N/A
Remarks
PERSONAL PROTECTION
Head Protection
Hearing Protection
“Safety” Glasses
Face shield
Respiratory protection
Safety full-body harness (man-lifts, above grade,
personnel baskets)
Protective clothing
Equipment guards on equipment
Foot protection
Gloves
ELECTRICAL TOOLS/EQUIPMENT
Covers on boxes, switches, receptacles (tight-fitting)
or double insulated
Power tools and appliances grounded
Welding machine grounded
Ground fault interrupters
Ground extension cord with good connectors
PNEUMATIC TOOLS/EQUIPMENT
Power tools secured to hose
Device at air source to reduce pressure if hose fails
PERMITS
Confined Space
Standby personnel
Hot Work
Fire extinguisher
Appropriate permit for work displayed
Permit has appropriate signatures
EXCAVATIONS AND TRENCHING
Sloping, stair-stepping or shoring of walls
Ladder or steps in hole/trench for quick exit
Warning tape or barriers installed
All nails on boards removed or bent over
20
Attachment G (cont.)
Date:
CONTRACTOR JOB SITE SAFETY CHECKLIST
Category
Acceptable N/A
Remarks
SCAFFOLDS/LADDERS
Ladders meet construction standards
Adequate footings
Scaffolds are plumb and secured
Toe boards/guard rails in place
Access ladder to elevated work platform
Ladders tied off
Adequate working platforms on scaffolds
COMPRESSED GAS CYLINDERS
Secure in an upright position
Metal valve caps must be in place on all cylinders not
in use
Store spare oxygen and combustible gas cylinders 20
feet apart or separated by a five foot high barrier
SUSPENDED LOADS
Secured by tag line to prevent swinging
No personnel working beneath load
Wire lines and connectors inspected/certified
FUEL CONTAINERS
Approved cans properly labeled
Storage of flammable liquids in designated areas only
Bulk storage of fuels vented, labeled
VEHICILE AND MOBILE EQUIPMENT
Backed-up alarms on mobile equipment
Load chart displayed inside equipment
Overhead guards on forklifts
WORKING SURFACES
Clear of tripping hazards
Non-slip surfaces on floors or ramps
Floor openings guarded
Stairs designed with hand rails, treads, risers, angles
that meet standards
WASTE DISPOSAL
Trash and rubbish removed daily
Hazardous wastes segregated for proper disposal
OTHER
COMMENTS
21
Attachment H
Date:
CONTRACTOR SAFETY REPORT
Contractor’s Name ____________________________
Project Manager /
_____________________________
Superintendent
Safety Representative _________________________
Month Ending ________________________________
Project Safety
________________________________
Coordinator
Project _____________________________________
INSTRUCTIONS: Complete Sections 2, 3 and 4. The Contractor Project Manager or Superintendent must sign
the report and return to the Schneider Electric Project Manager.
1.
SIGNIFICANT ACCOMPLISHMENTS, INCIDENTS, NEAR MISSES, OR ISSUES REQUIRING SPECIAL
ATTENTION (log daily activities here)
2.
HAZARDOUS MATERIALS USED ON SITE/SHIPPED OUT
Date(s)
3.
Substance
Description
Unused Total
In Storage
Gallons of
Waste Generated
Total Gallons of
Waste in Storage
SAFETY MEETINGS/TOOL BOX TALKS
Date(s)
Conducted by
4.
Topic Description
No. of Participants
INJURY ANALYSIS STATUS
TOTAL MAN-HOURS
NUMBER OF EMPLOYEES
TOTAL OSHA RECORDABLES
TOTAL LOST TIME ACCIDNTS
TOTAL LOST TIME WORKDAYS
Superintendent
SIGNATURES
Contractor Site
_____________________________
Date _______________________________________
Project Safety
Contractor Safety
Coordinator ________________________________
Representative _______________________________
NOTE: Please attach additional information with this form as needed.
22
Attachment I
Date:
CONTRACTOR SAFETY PROGRAM TRAINING LOG
Instructor: _____________________________
I have trained the employees listed below on the Contractor Safety Program.
Instructor Signature: ____________________________
Employee Name
Employee Signature
Department
Date
23
Attachment J
Hold Harmless Agreement
Date:
Date:
To:
_________________
_________________
_________________
_________________
Dear
Subject:
Enclosed are our insurance requirements and a copy of our Indemnification and Hold
Harmless Agreement. Prior to any _________ work being started, the Contractor(s) must
comply with our insurance requirements, as evidenced by them forwarding a Certificate of
Insurance meeting the amounts outlined on the enclosed, and they must execute the Hold
Harmless Agreement, and forward it to my attention. They can fax them to me at (847) 9257378.
Thanks for your help with this matter.
Sincerely,
________________
cc:
24
Attachment J (Cont.)
(Page 1 of 3)
INDEMNITY AND SAVE HARMLESS AGREEMENT
The undersigned party (hereinafter the CONTRACTOR), as inducement for, and as
consideration for, the execution by SCHNEIDER ELECTRIC/SQUARE D COMPANY
(hereinafter the COMPANY) of the purchase order or agreement identified below (hereinafter
the CONTRACT) and notwithstanding any terms or conditions of the Contract to the contrary,
agrees to protect, defend, indemnify and save harmless the COMPANY and its parent,
subsidiary and affiliated companies, if any, from and against any and all liability, loss,
damage, expense, claims and demands of every kind and character (hereinafter damage
claims), arising from the negligence of the CONTRACTOR, whether due to the
CONTRACTOR’S joint or sole negligence, provided, however, that the Contractor shall not
be liable by reason of this agreement for any payment of damages to the extent arising out of
damage claims resulting from the negligence of the COMPANY. The CONTRACTOR shall
at its own expense investigate all damage claims, except those damage claims resulting from
the negligence of the COMPANY, and shall defend any and all actions based thereon and
shall pay all costs, damages, awards and expenses of whatever nature, including attorney’s
fees arising from the joint or sole negligence of the CONTRACTOR. For the purpose of this
agreement, violation of an applicable safe place statute by the CONTRACTOR will constitute
negligence and any damage claims arising out of such negligence shall be subject to the
provisions of this agreement. The CONTRACTOR agrees to furnish the COMPANY with a
certificate, in a form satisfactory to the COMPANY, evidencing that the foregoing obligations
are adequately covered by policies of insurance issued by a carrier satisfactory to the
COMPANY.
Identification of Contract:
Name of Contractor
(Authorized Signature)
By:
Title:
Date:
ISHA~SQD.doc
3/9/16
25
Attachment J (Cont.)
(Page 2 of 3)
Contractor shall maintain in force at all times during the course of this work at least the
following types and amounts of insurance with insurance companies rated A or better and
financial size not less than X by A. M. Best Company:
Contractor Category A
Amount of Insurance
Contractor Category B
Amount of Insurance
Workers' Compensation (U.S. Only)
(Alternatively Contractor can supply
proof as a state qualified selfinsured company)
Statutory
Statutory
Employers' Liability (U.S. Only)
$100,000
Each Accident and
Disease
$500,000
Each Accident and
Disease
Comprehensive General Liability
Insurance (Written on a
Comprehensive Occurrence Form)
including the following:
Combined Single Limit
Bodily Injury and Property
Damage
$500,000 Per Occurrence
Combined Single Limit
Bodily Injury and Property
Damage
$2,000,000 Per
Occurrence
Combined Single Limit
Bodily Injury and Property
Damage
$500,000 Per Occurrence
Combined Single Limit
Bodily Injury and Property
Damage
$2,000,000 Per
Occurrence
Description of Coverage
• Premises/Operations
Liability
• Products/Completed
Operations Liability
• Contractual Liability
(To cover the Indemnity and
Save Harmless Agreement)
• Broad Form Property Damage
• Independent Contractors
(Required if Contractor
employs subcontractors for
work or service)
Automobile Liability Insurance for
any Auto Owned, Non-owned,
Leased, Rented or Hired and used
in the fulfillment of this agreement
26
Attachment J (Cont.)
(Page 3 of 3)
An Umbrella or Excess Liability policy may be used to increase basic limits to the required
levels.
Contractor Category A:
Contractors who provide work or service (including work or service on electrical systems less
than 110 volts) which does not involve the use of ladders over 8’ in length, scaffolding, power
tools (other than small power hand tools), cutting/welding equipment or heavy machinery.
Contractor Category B:
All other categories of work or service as defined in this procedure including Contractors who
do not qualify under Contractor Category A above.
Certificate of Insurance:
Prior to commencing work, and thirty (30) days prior to the expiration of any insurance
required herein, Contractor shall furnish Square D Company with a Certificate of Insurance,
in a form acceptable to Square D Company. The Certificate of Insurance must be signed by
an authorized representative of Contractor’s insurance company and show that the insurance
coverages and limits of liability shown above are being provided by Contractor’s insurance
company, showing the effective and expiration dates, policy numbers and insurer,
acknowledging Contractual Liability Insurance for this Agreement, name Square D Company,
its parent company and subsidiaries, and their directors, officers and employees as an
additional named insured under their Comprehensive General Liability Insurance policy and
waive right of subrogation against Square D Company under Workers’ Compensation
Insurance. The Certificate of Insurance shall also contain the following statement: “No
reduction, cancellation or expiration of any of these insurance policies shall become effective
until at least thirty (30) days written notice thereof is received by Square D Company.”
Contractor hereby agrees to execute the Indemnity and Save Harmless Agreement attached
hereto and made a part of this Agreement, prior to commencement of the work.
The insurance requirements shall survive this Agreement. Square D Company shall have no
obligation to review or verify the existence of Contractor’s insurance. The consent of Square
D Company to the insurance and limits shown above shall not be considered as a limitation
of Contractor’s liability under this Agreement nor an Agreement by Square D Company to
assume liability in excess of said amounts or for risks not insured hereunder. Failure of
Contractor to maintain complete insurance does not lessen Contractor’s liability and may be
deemed a material breach allowing Square D Company to terminate this Agreement.
3/9/16
ContractorA.DOC