Subcontractor Safety Prequalification

Pre-Contract Safety Evaluation

This information must be provided by all subcontractors prior to issuance of any contract for service by August Winter & Sons, Inc. It shall be made available upon written request by any customer requesting information on subcontractors selected for specific projects.

🏢 Company Information

Company Name *

Type of Company *

Type of Work Performed *

Street Address *

City / State / Zip *

Phone Number *

Fax Number

Principal Contact *

Email Address *

Year Business Established *

States You Work In *

Union or Non-Union *

Union Non-Union

Previous Company Name

Federal Tax ID (EIN) *

AWS Vendor # (if known)

Contractor's License #

D&B #

⛑ Safety Information — OSHA 300 Log Data

List your Company's injuries/illnesses from your OSHA 300 Logs for the most recent three years. *

Metric	Last Year	1st Prior Year	2nd Prior Year
Experience Modification Rate (EMR)
Total Fatalities (Col. G)
Total OSHA Recordable Incidents (Cols. I + J)
Total Lost Work Day Incidents (Col. H)
Total OSHA Citations Received
Total Annual Hours Worked

Factors Requiring Safety Department Variance

Deaths
TRIR greater than 1.0
EMR greater than 1.0
OSHA Violations in the last 3 years

✓ Safety Programs & Controls

Please indicate whether your company implements the following safety controls. *

Has a Written Safety Program

Yes No

Has an Implemented Drug Screening Policy for all Employees

Yes No

Performs Safety Orientation & Training for all Employees

Yes No

Performs Continuing Safety Education for all Employees

Yes No

👤 Safety / Health Professional Contact

Name *

Title *

Phone Number *

Email Address *

Notice: Incomplete or unsatisfactory responses to the questions may result in your company not being selected as a subcontractor on certain projects. If this is the case you will be notified by the project manager bidding the project. Failure to completely fill out this form may result in your company not being selected as a subcontractor for August Winter & Sons, Inc.

✓

Submission Received

Thank you. Your safety prequalification has been submitted to August Winter & Sons, Inc. for review.