Subcontractor Pre-Qualification Assessment

Admin Only

Subcontractor Light Rating

For Admin Use only

NOTICE: The IWS Safety Support Center is located at www.iws.support!

All the information requested in this document for your company can be found for IWS by visiting our Safety Support Center.

Date*

Date

Subcontractor Name*

Designated Safety Representative Name*

First NameLast Name

Designated Safety Representative Email*

example@example.com

Designated Safety Representative Phone Number*

Please enter a valid phone number.

Company Website

Commercial General Liability (GCL) Carrier

Commercial General Liability (GCL) Carrier Policy Number

Commercial General Liability (GCL) Carrier Phone Number

Please enter a valid phone number.

Evaluation Rating and Acceptance

The subcontractor rating system consists of five designations:

90 points or higher= Green Light
75 to 89 points= Orange Light – A mitigation plan must be documented and approved by the Company Safety Department.
Below 75 points= Red Light – Must subscribe to OpsIntegrity.
No formal safety management system= Not-Approved – Must subscribe to OpsIntegrity.

Once each subcontractor has been evaluated and scored, the Company Safety Team will provide management with the corresponding score and light status.

Integrated Water Services reserves the right to change a subcontractor’s status to “Not-Approved” if they fail to demonstrate sufficient progress towards an accepted mitigation plan or other agreed-upon criteria.

Subcontractor Involvement

Subcontractors are required to implement and adhere to the following safety practices and systems at all times while working at Company worksites:

Attend a safety orientation included in any pre-job or kickoff meeting conducted by the Company before work begins.
Monitor employees for substance abuse and handle all violations in accordance with the subcontractor's internal policies and procedures.
Ensure all personnel have the required training and competency for their assigned work.
Participate/support in Company tailgate safety meetings, job safety analyses (JSA), hazard assessments, and on-the-job safety inspections.
Conduct a pre-job hazard assessment prior to starting work.
Participate in the Behavior-Based Safety (Good Catch) reporting system.
Report all injuries, spills, property damage incidents, and near-miss events.
Comply with onsite and Owner/Client safety rules.
Implement and comply with all applicable Company safety practices and procedures.
Clean up and restore your work area upon job completion.
Ensure compliance with all applicable safety regulations at all times.

Injuries/Hours:

	EMR	Total hours Worked	Recordable Injuries	Lost Time Injuries	Fatalities
Last Year
2-Years Ago
3-Years Ago

OSHA Citations:

	Number of OSHA Citations	Reason for Citation
Last Year
2-Years Ago
3-Years Ago

1. Do you have a formal Safety Management System (SMS)?

YesNoN/A

2. Do you have a Drug and Alcohol program?

	Yes	No	N/A
a. Pre-employment Testing
b. Reasonable Cause Testing
c. Post-Rehabilitation/Return to Work Testing

3. General Safety Programs & Policies

	Yes	No	N/A
a) Health, Safety, and Environmental (HSE) Policy Statement signed by management
b) Management Involvement and Commitment to safety initiatives
c) Safety Training Program for all employees
d) Safety Orientation for new hires and site-specific training
e) Self-Safety Assessments conducted periodically [NEW]
f) Policies, Procedures, and Best Work Practices documented and implemented
g) Safety Meetings Conducted (frequency and documentation required)
h) Incident and Accident Reporting and Investigation Procedures

4. Hazard Identification & Risk Management

	Yes	No	N/A
a) Behavior Based (Good Catch) Program
b) Hazard Communication (Right to Know & Safety Data Sheets - SDS)
c) Hazard Identification and Risk Control Program
d) Unsafe Condition Reporting Program
e) Workplace Assessment, Inspection, and Audit Program
f) Permit-to-Work System for high-risk tasks
g) Emergency Management Plan (including evacuation, medical emergencies, and response to hazardous events)

5. Workplace & Equipment Safety

	Yes	No	N/A
a) Good Housekeeping Policy
b) Motor Vehicle Driving Safety Policy
c) Vehicle and Equipment Inspections (documented and performed regularly)
d) Powered Industrial Vehicle Safety Program (Cranes, Forklifts, etc.)
e) Portable Electrical/Power Tools Safety Policy
f) Electrical Equipment Grounding Assurance Program

6. Personnel Training & Protective Equipment

	Yes	No	N/A
a) First Aid/CPR Trained Workers Onsite
b) Where applicable, have employees been trained, fit-tested, and medically approved
c) Respiratory Protection Program
d) Personal Protective Equipment (PPE) Provided to Employees
e) Fall Protection Program (including equipment and training)
f) Confined Space Entry Program (procedures, permits, and training)
g) Hot/Cold Stress Prevention Program

7. Chemical & Environmental Safety

	Yes	No	N/A
a) Spill Prevention, Control, and Countermeasure (SPCC) Program
b) Compressed Gas Cylinder Handling and Storage
c) Waste Disposal and Pollution Prevention Plan
d) Environmental Compliance Program

8. Do you plan to use subcontractors on IWS locations?

YesNoNot Sure

9. Do you maintain safety and training records in accordanance with applicable laws?

YesNoNot Sure

Upload Safety Manual and OSHA 300A Log for last year

Subcontractor Safety Pre-Qualification Assessment

1. General Information

2. INSURANCE

3. Evaluation Rating and Acceptance

4. Safety KPIs

5. Questionnaire