Subcontractor / Supplier Prequalification Form Page 4
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5Highest ranking safety/health professional in the company:
Title:
Phone:
Fax:
Email:
Are you willing to provide safety & task training as required by OSHA and/or Allied/Cook for your employees
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and subcontractors?
Yes
No
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Does your company provide a health insurance plan to your employees?
Yes
No
If yes, what percentage of cost is covered by your company?
%
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Do you have a written Safety & Health Program?
Yes
No
Do your employees read, write, and understand English such that they can perform their job tasks safely
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without an interpreter?
Yes
No
If no, provide a description of your plan to assure they can safely perform their jobs.
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Do you have personnel trained to perform first aid & CPR?
Yes
No
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Do you hold documented site safety & health meetings?
Yes
No
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Is applicable Personal Protection Equipment (PPE) provided for employees?
Yes
No
Do you conduct inspections on operating equipment (e.g. cranes, forklifts, JLGs) in compliance with
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regulatory requirements?
Yes
No
Form Completed by:
Title:
Email:
This document must be signed by a company officer.
Signature
Title
Date
Print Name
AlliedCook Construction 11.09
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prequalification form.doc
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