Subcontractor Pre-Qualification Form (PQF)

Roux Associates, Inc. (Roux Associates) is committed to operating in a safe, reliable and environmentally-sound manner for the benefit of its employees, clients, subcontractors, visitors and communities where its work is performed. Roux Associates’ employees work to assure that potential physical, mechanical, chemical and health hazards are recognized, safe operating practices are routinely performed, and appropriate protective measures are provided.

You are being asked to complete the form below to give Roux Associates the information it needs to ensure that your company has the appropriate health and safety policies, practices and procedures in place to work for, or continue to work for, Roux Associates. Working in varied environments presents hazards that can be adequately addressed with the right systems in place so that Roux Associates and its subcontractors mutually achieve and maintain incident-free projects where no one gets hurt.

General Information
Company Name
Telephone Fax
Email of 2 contacts for safety communication:  
Mailing Address
Parent Company Name
Other Names company trades/operates under:
This PQF is being completed by:
Name: Title:
Phone: Email:
Health & Safety Management
Highest ranking health/safety professional in Company:
Name: Title:
Phone: Email:
Health & Safety Performance
EMR: Workers' Compensation Experience Modification Rate (EMR) Data for last three completed years:
Year: 2007Rate:
Year: 2006Rate:
Year: 2005Rate:
***IMPORTANT NOTE 1***: If Company EMR is higher than 1.0 for two of the last three years, please provide an explanation report for the high EMR and describe the steps being taken to improve Company performance. If this report is not provided, the Company PQF cannot be processed.
HOURS:Employee hours worked for the last three years (excluding sub-contractors)   Year: 2007 Year: 2006 Year: 2005
Field Hours
Total Hours
INJURY AND ILLNESS DATA: Provide the following data (excluding subcontractors) using Company OSHA 300 Forms from the last three years: # of InjuriesRate # of InjuriesRate # of InjuriesRate
Injury/Illness Related Fatality Rate = Number of Cases x 200,000 / Total Employee Hours
Injury/Illness Involving Days Away From Work Rate = Number of Cases x 200,000 / Total Employee Hours
Injury/Illness Involving Job Transfer or Restriction Rate = Number of Cases x 200,000 / Total Employee Hours
Injury/Illness Involving Medical Treatment (other recordable case) Rate = Number of Cases x 200,000 / Total Employee Hours
Total OSHA Recordable Injury/Illness Rate = Total Number of Cases x 200,000 / Total Employee Hours
***IMPORTANT NOTE 2***: If Company Total OSHA Recordable Injury/Illness Rate is higher than 6.3 for two of the three years, please provide an explanation report for the high Rates and describe the steps being taken to improve Company performance. If this report is not provided, the Company PQF cannot be processed.
***IMPORTANT NOTE 3***: If the Company is not required to maintain OSHA 300 forms, please provide information on its safety experience for the last three years. Also provide information from the Company's Workers' Compensation Insurance carrier itemizing any and all Workers' Compensation claims for the last three years. If this report is not provided, the Company PQF cannot be processed.
Note: If data above are specific to a certain area or division, please describe the distinction.
CITATIONS: Has Company received any regulatory (OSHA, EPA, etc.) citations in the last three years? YES If Yes, please attach copies of the descriptions of findings and Company's corrective actions.
NO
STEP 2: DOCUMENTS TO SEND
After submitting this form, please email/mail the following items to Roux Associates:
Please provide copies of the following items with the completed PQF:
EMR documentation from the Company's insurance carrier for the last three years
OSHA 300 Logs for the last three years
Any regulatory (OSHA, EPA, etc.) citations that the Company has received in the last three years with documentation of corrective actions taken by the Company
Company Health & Safety Policy
Company Health & Safety Program Table of Contents
Company Health & Safety Handbook Table of Contents
A description of what you believe will be the "most significant hazard" in performing the Company's work and the steps or actions that will be taken to minimize/eliminate this "most significant hazard"