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(updated 3/8/05


Rohm and Haas is dedicated to improving contractor Environmental, Health and Safety
(EH&S) practices on company jobsites and the first step in doing this is selecting
qualified contractors. The attached Contractor Pre-Qualification Form is designed to
provide information for Rohm and Haas to evaluate a contractor’s EH&S performance
and programs.
The attached form is a variation of the Houston Business Roundtable (HBR)
Standardized Pre-Qualification Form (PQF). The major subjects addressed by this
survey are the contractor’s work history and its EH&S performance, management
programs, procedures and training. The form should be filled out with as much detail as
possible so that Rohm and Haas will be able to make an accurate evaluation of your
company’s EH&S records and policies. In addition to answering the questions, please
furnish copies of the documents requested by the Information Submittal section at the
end of the form. This will help us evaluate your company’s position and dedication to a
quality EH&S program.
Rohm and Haas thanks you in advance for your time and efforts in completing this
evaluation form, and most of all to your commitment to protecting your employee’s
health and safety.

Yes Telephone: Fax: Telephone: Fax: No PQF Completed By: Title: ORGANIZATION 11.Standardized Pre-Qualification Form (PQF) GENERAL INFORMATION 1. etc. Contact for Insurance Information: Title: Telephone: 7. Company Name: Telephone: Fax: Street Address: Mailing Address: Contact Person: email: Officers Years With Company President: Vice President: Treasurer: 3..Rohm and Haas . Under Current Management Since (Date): 6. Form of Business: Sole Owner 12. clerical.g. Describe Services Performed: Partnership Corporation EEO Category: Construction Construction Design Original Equipment Manufacturer and Installer SIC Code:________________________________ Original Equipment Manufacturer and Maintenance Service work (e. Are you self insured for Worker’s Compensation Insurance? 9. Contact for Requesting Bids: Title: 10.) Project Maintenance Manpower and Resource Maintenance Other . 2. janitorial. How many years has your organization been in business under your present firm name? 4. Insurance Carrier(s): Name Fax: Type of Coverage Telephone 8. Percent Minority/Female Owned: 13. Parent Company Name: City: Tax ID#: Zip: State: Subsidiaries: 5.

Yes Are you now or have you ever been involved in any bankruptcy or reorganization proceedings? If yes. D&B Financial Rating: Net Worth: $ 20_____ $ 20_____ $ $ 20_____ $ Bonding Capacity: Annual Sales $ Minimum: COMPANY WORK HISTORY 23. EMR for three last years: 200 200 200 d. List other types of work within the services you normally perform that you subcontract to others: 16. Dual rate State of Origin: No . Yes SAFETY & HEALTH PERFORMANCE 27. Describe Additional Services Performed: 15. list trades/locals: 17. Annual Dollar Volume for the Past Three Years: 20. please attach details. Your Firm’s Desired Project Size: Maximum: 22. List Company Paid Benefits provided your employees: 19. Largest Job During the Last 3 Years: 21. Average number of employees for last 3 years: 18. Customer Contact Telephone Size $M Customer Contact Telephone Major jobs completed in the past three years: Type of Work Customer/Location 25. Major jobs in progress: Type of Work Customer/Location 24.14. please attach details. 26. EMR Anniversary Date: Interstate rate Intrastate rate Monopolistic State rate c. No Workers Compensation Experience Modification Rate (EMR) Data a. Do you normally employ? Union Personnel. Size $M Are there any judgments. Non-Union Personnel. Leased Personnel If union. claims or suits pending or outstanding against your company? If yes. EMR is: b.

Full time Safety/Health Director Yes No b. Employee hours worked last three years (excluding subcontractors) Hours / Year 200_ 200_ 200_ Field Total b.000 divided by Total Employee Hours Total OSHA Recordable Injury/Illness Rate (OII) OII Rate = Total Recordable Injury/Illness cases x 200. Injury and Illness Data: a. Safety/Health incentive program Yes No b. Rate Total Lost Workday Case Rate. please attach copies.000 divided by Total Employee Hours List number of Injuries/Illnesses that resulted in fatalities and provide specific details on those incidents. OSHA. Notes: 29. 32. please provide information from your Worker’s Compensation insurance carrier itemizing all claims for the last three years. Yes No SAFETY & HEALTH MANAGEMENT 30. Telephone: Fax: Do you have or provide: a. etc.) citations in the last three years? If yes. Full Time Job Safety/Health Coordinator Yes No Do you have or provide: a. Have you received any regulatory (EPA. Highest ranking safety/health professional in the company: Title: 31. Provide the following data (excluding subcontractor) using your OSHA 200 and 300 Forms from the past three (3) years: 200_ No. including both Lost Time and Restricted Duty Injuries/Illnesses LWC Rate = Total Lost Time and Restricted Duty Injury/Illness cases x 200.28. 200_ Rate No. Rate 200_ No. Company paid safety/health training Yes No SAFETY & HEALTH PROGRAMS & PROCEDURES . If your company is not required to maintain OSHA 300 forms. Full time Site Safety/Health Supervisor Yes No c. (1) (2) Data should be the best available data applicable to the work in this region or area.

Waste Disposal Yes No Do you have written programs for the following: a. d. 36.) Yes No k. Powered Industrial Vehicles (Cranes. 35. and understand English such that they can perform their job tasks safely without an interpreter? Yes If no. have employees been: Trained Yes No Yes No Yes No Yes No Fit tested Medically approved c. Personal Protective Equipment Yes No f. Injury & Illness Recording Yes No d. Accident/Incident Reporting Yes No m. Fall Protection Yes No e. Respiratory Protection Where applicable. Housekeeping Yes No l. Do you have a written Safety and Health Program? Yes No Does the program address the following key elements? • Management commitment and expectations Yes No • Employee participation Yes No • Accountabilities and responsibilities for managers. No . and employees Resources for meeting safety & health requirements Yes No Yes No Periodic safety and health performance appraisals for all employees Hazard recognition and control Yes No Yes No Equipment Lockout and Tagout (LOTO) Yes No • • • 34. Yes No Yes No • Random Testing Yes No • Testing for Cause Yes No • DOT Testing Yes No Do your employees read. etc. Portable Electrical/Power Tools Yes No g.33. does it include the following? • Post Accident Testing Pre-placement Testing 37. write. Compressed Gas Cylinders Yes No i. b. Do you have a substance abuse program? If yes. Vehicle Safety Yes No h. Explosives and Blasting Agents Standard (29 CFR 1910). Forklifts. Electrical Equipment Grounding Assurance Yes No j. including evacuation plan Yes No o. provide a description of your plan to assure that they can safely perform their jobs. Unsafe Condition Reporting Yes No n. JLGs. Hearing Conservation Yes No b. Hazard Communication Program to support the contractor requirements of the OSHA Process Safety Management of Highly Hazardous Chemicals. Confined Space Entry Yes No c. Emergency Preparedness. supervisors. Does the program include work practices and procedures such as: a.

g. Do you maintain the applicable inspection and maintenance certification records for operating equipment? 43. Do you have a program to assure that PPE is inspected and maintained? 41. Do you conduct inspections on operating equipment (e. Is applicable PPE provided for employees? b. cranes. JLGs) in compliance with regulatory requirements? c. Do your subcontractors have a written Safety & Health Program? d. Do you maintain operating equipment in compliance with regulatory requirements? d. Do you have a corrective action process for addressing individual safety and health performance deficiencies. No Personal Protection Equipment (PPE) a. Do you include your subcontractors in: • Safety & Health Orientation Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No • Safety & Health Meeting Yes No • Inspections Yes No • Audits Yes No Yes No Inspections and Audits a. Do you conduct safety and health inspections? b. Specify who will provide this service: Do you have personnel trained to perform first aid and CPR? Yes No Yes No Yes No Yes No Do you hold site safety and health meetings for: Field Supervisors Yes No Frequency Employees Yes No Frequency New Hires Yes No Frequency Subcontractors Yes No Frequency Are the safety and health meetings documented? 40. No Yes 42. 44. Do you have a system for establishing applicable health. c. Do you evaluate the ability of subcontractors to comply with applicable health and safety requirements as part of the selection process? c. Do you conduct medical examinations for: • Pre-placement Yes No Preplacement Job Capability Yes No • Hearing Function (Audiograms) Yes No • Pulmonary Yes No • b. Subcontractors a.. safety.38. and environmental specifications for acquisition of materials and equipment? b. Do you use safety and health performance criteria in selection of subcontractors? b. • Respiratory Yes Describe how you will provide first aid and other medical services for your employees while on-site. Do you conduct safety and health program audits? Yes No c. 39. Are corrections of deficiencies documented? Yes No . forklifts. Equipment and Materials: a. Medical a.

Craft Training a. c.SAFETY & HEALTH TRAINING 45 46. Have employees been trained in appropriate job skills? b.) Written test Job Monitoring Oral test Performance test Other (List) . Supervisors Method used to verify understanding How do you verify understanding of training? (Check all that apply. b. Do you know the regulatory safety and health training requirements for your employees? b. List crafts which have been certified: Yes No Yes No Safety & Health Orientation New Hires a. Do you have a specific safety and health training program for supervisors? Yes No Yes No Yes No Yes No Yes No Date of training Yes No Name of trainer Yes No Yes No Training Records a. Do you have a Safety & Health Orientation Program for new hires and newly hired or promoted supervisors? Does program provide instruction on the following: • New Worker Orientation Yes No Yes No Yes No Yes No • Safe Work Practices Yes No Yes No • Safety Supervision Yes No Yes No • Toolbox Meetings Yes No Yes No • Emergency Procedures Yes No Yes No • First Aid Procedures Yes No Yes No • Incident Investigation Yes No Yes No • Fire Protection and Prevention Yes No Yes No • Safety Intervention Yes No Yes No Yes No Hours Yes No • Hazard Communication How long is the orientation program? Safety & Health Training a. 47. Have your employees received the required safety and health training and retraining? c. 48. Do the training records include the following: Employee identification c. Are employees job skills certified where required by regulatory or industry consensus standards? c. Do you have safety and health and crafts training records for your employees? b.

OWNER USE ONLY -DO NOT FILL OUT .) Note: Owner checks items to be provided with PQF.INFORMATION SUBMITTAL Please provide copies of checked ( ) item with the completed PQF: (Note: Minimum submital requirements pre-marked) X EMR documentation from your insurance carrier X Insurance Certificate(s) OSHA 200/300 Logs (Past 3 Years) Safety & Health Program Safety & Health Incentive Program Substance Abuse Program Hazard Communication Program Respiratory Protection Program Housekeeping Policy Accident/Incident Investigation Procedure Unsafe Condition Reporting Procedure Safety & Health Inspection Form Safety & Health Audit Procedure or Form Safety & Health Orientation (Outline) Safety & Health Training Program (Outline) Example of Employee Safety & Health Training Records Safety & Health Training Schedule (Sample) Safety & Health Training for Supervisors (Outline) Organization Chart _____ List of your major equipment (e. etc. JLG’s. cranes.g. _____ PQF EVALUATION -.OWNER USE ONLY Contractor is: Acceptable for Approved Contractor List Conditionally acceptable for Approved Contractor List Conditions: Reviewer: Date: . forklifts.