Get Ucn-21752 Seller Safety Qualification Questionnaire - Y12 Doe

This guide will assist users in accurately completing the UCN-21752 Seller Safety Qualification Questionnaire - Y12 Doe online. By following the step-by-step instructions, users can ensure that all required information is provided, enhancing their chance of a successful submission.

Follow the steps to efficiently complete the questionnaire.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering requisition number and subcontractor's name in the provided fields. Ensure that these details are accurate, as they are critical for your bid documents.
3. Fill out question 1 by listing all names under which your firm has operated for the past ten years. If more space is required, attach an additional sheet and reference the question.
4. For question 2, input your firm's insurance interstate experience modification rate (EMR) for the last three years. If intrastate rating is applicable, use that instead.
5. In question 3, provide the names and documentation of any other sources, beyond your current worker's compensation insurance carrier, that cover medical costs for work-related injuries or illnesses. If no additional sources exist, indicate that clearly.
6. Attach your company’s OSHA 300-A log, which summarizes work-related injuries and illnesses for the past three years as requested in question 4.
7. Question 5 requires you to list the names, phone numbers, and a contact person from up to five companies you have collaborated with in the last ten years, emphasizing your safety performance.
8. In question 6, provide your firm's injury statistics rates for the past three years using the OSHA formula. Clearly indicate the method used if a different approach applies.
9. Answer question 7 by listing any OSHA citations your firm has received in the last five years, detailing the type, standard cited, and resolution of these citations if applicable.
10. Respond to questions 8 and 9 by including your firm's written environmental, safety, and health program document if not already on file with CNS, as well as your hazard communication program.
11. In question 10, list your safety and health professional(s) and how much of their time is dedicated to safety matters.
12. For question 11, determine if your firm maintains a safety committee program and provide necessary details about the organization and frequency of safety meetings as per subsequent questions.
13. Complete question 14 by confirming whether field safety audits are performed and whether tracking of safety deficiencies occurs.
14. In question 15, clarify if your company has previously worked at the Y-12 National Security Complex, providing relevant years and prime contractor(s) if a subcontractor.
15. Finally, certify that all provided information is accurate and complete. Include the necessary signature, typed or printed name, title, and address at the end.
16. Save your changes, download a copy of the completed form, or share it as needed once you have filled it out completely.

Start filling out your UCN-21752 Seller Safety Qualification Questionnaire online today to ensure a smooth and efficient application process.