ND Paper Contractor Safety Qualification Form

"*" indicates required fields

General Company Information

All contractors planning to perform work onsite an ND Paper mill are required to fill out this form.

This form also includes our Personal Protective Equipment (PPE) Policy.

Name*

Company Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Safety Contact*

Safety Contact Email*

Safety Contact Phone Number*

Company Email Address*

Office Phone Number*

Mill/site(s) where service/material will be rendered/supplied*

Biron

Chicago

Dayton

Fairmont

Langhorne

Old Town

Rumford

Sturtevant

Contractor Safety Record

Please state your Current Insurance Carrier

EMR 2 Years Prior

TCIR 2 Years Prior

LTIR 2 Years Prior

Fatalities 2 Years Prior

EMR for Prior Year

TCIR for Prior Year

LTIR for Prior Year

Fatalities for Prior Year

EMR for Current Year

TCIR for Current Year

LTIR for Current Year

Fatalities for Current Year

Please attach a letter from your insurance broker that verifies your current year EMR.*

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 800 MB.

Contractor Safety Questions - Current Year

Contractors MUST complete this section: please report accurately the requested information below for year-to-date current year. If you are not a contractor, please indicate "N/A" in all lines. If your company has greater than 10 employees then please upload the previous 3 years of OSHA 300 logs.

# of OSHA Lost Workday Cases*

# of OSHA Lost Work days Recorded*

# of Recordable Medical Cases*

# of Fatalities*

Total Hours Worked*

Lost-time Incident Rate (Multiply the # of cases by 200,000 hours and divide by Total Hours Worked)*

Recordable Incident Rate (Multiply the # of cases by 200,000 hours and divide by Total Hours Worked)*

# of Fire Incidents*

# of Crane Incidents*

# of Commercial Auto Incidents (e.g., autos, pick-ups, vans, etc.)*

# of Industrial Auto Accidents (e.g., graders, scrapers, tractors, off-highway trucks, hydraulic excavators, skidders, fork trucks, etc.)*

# of Environmental Impact Incidents (e.g., splits, solid/hazardous waste releases)*

Contractor Safety Questions - Prior Year

Contractors MUST complete this section: please report accurately the requested information below for prior year. If you are not a contractor, please indicate "N/A" in all lines.

# of OSHA Lost Workday Cases*

# of OSHA Lost Work days Recorded*

# of Recordable Medical Cases*

# of Fatalities*

Total Hours Worked*

Lost-time Incident Rate (Multiply the # of cases by 200,000 hours and divide by Total Hours Worked)*

Recordable Incident Rate (Multiply the # of cases by 200,000 hours and divide by Total Hours Worked)*

# of Fire Incidents*

# of Crane Incidents*

# of Commercial Auto Incidents (e.g., autos, pick-ups, vans, etc.)*

# of Industrial Auto Accidents (e.g., graders, scrapers, tractors, off-highway trucks, hydraulic excavators, skidders, fork trucks, etc.)*

# of Environmental Impact Incidents (e.g., splits, solid/hazardous waste releases)*

Contractor Safety Questions - 2 Years Prior

Contractors MUST complete this section: please report accurately the requested information below for 2 years prior. If you are not a contractor, please indicate "N/A" in all lines.

# of OSHA Lost Workday Cases*

# of OSHA Lost Work days Recorded*

# of Recordable Medical Cases*

# of Fatalities*

Total Hours Worked*

Lost-time Incident Rate (Multiply the # of cases by 200,000 hours and divide by Total Hours Worked)*

Recordable Incident Rate (Multiply the # of cases by 200,000 hours and divide by Total Hours Worked)*

# of Fire Incidents*

# of Crane Incidents*

# of Commercial Auto Incidents (e.g., autos, pick-ups, vans, etc.)*

# of Industrial Auto Accidents (e.g., graders, scrapers, tractors, off-highway trucks, hydraulic excavators, skidders, fork trucks, etc.)*

# of Environmental Impact Incidents (e.g., splits, solid/hazardous waste releases)*

Consultant and Engineer Safety Questions - Current Year

Consultants and Engineers MUST complete this section: please report accurately the below requested information for year-to-date current year. If you are not a consultant/engineer, please indicate "N/A" in all lines.

# of Hours Worked*

# of Lost-time Injuries*

# of Work-related Injuries*

# of Fatalities*

Consultant and Engineer Safety Questions - Prior Year

# of Hours Worked*

# of Lost-time Injuries*

# of Work-related Injuries*

# of Fatalities*

Consultant and Engineer Safety Questions - 2 Years Prior

# of Hours Worked*

# of Lost-time Injuries*

# of Work-related Injuries*

# of Fatalities*

Policies and Procedures

Do you have the following policies and procedures?

Accident/Incident Reporting Procedure*

Yes

N/A

Confined Space Entry Program*

Yes

N/A

Employee Assistance Program (EAP)*

Yes

N/A

First Aid Procedures*

Yes

N/A

Hazard Communication Training*

Yes

N/A

Incident Review Program*

Yes

N/A

Personal Protective Equipment Policy*

Yes

N/A

Process Safety Management Policy*

Yes

N/A

Respiratory Protection Policy*

Yes

N/A

Substance Abuse Program*

Yes

N/A

Zero Energy Program*

Yes

N/A

Most Current NFPA-70E*

Yes

N/A

Please attach copies of previous 3 years complete OSHA logs with employee names redacted.*

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 800 MB.

Please list any OSHA Citations/Penalties in the last 5 years.*

Please attach a copy of all OSHA citations.*

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 800 MB.

Please attach a copy of your Disciplinary Procedures for Safety Infractions.*

Drop files here or

Accepted file types: pdf, doc, docx, png, jpg, jpeg, Max. file size: 800 MB.

List any OSHA audits received in the last 5 year.*

Describe how the company holds its subcontractors accountable for safety compliance?*

ND Paper Contractor Safety, Environmental and Security Policy

Please read the ND Paper Contractor Safety, Environmental and Security Policy here.

ND Paper PPE Policy & Safety, Environmental & Security Policy Acknowledgement

I certify understanding and will comply by the ND Paper PPE Policy when performing work on ND Paper site(s).*

Yes

ND Paper Contractor Safety Qualification Form

Certification of Accuracy

As a representative of the company, I confirm the foregoing information is complete and accurate. I understand it is our organization's responsibility to ensure that all of our employees, subcontractors, vendors, service representatives, etc., working in any ND Paper facility or location have read, understand, and are held accountable for following all of ND Paper's Environmental, Health & Safety (EHS) Requirements. A copy of "ND Paper Contractor Safety, Environmental and Security Policy" has been provided to us. By checking "Yes" below, I acknowledge understanding and acceptance.*

Yes

Vendor Legal Entity Name*

Today's Date*

MM slash DD slash YYYY

Name of Authorized Signatory*

Title of Authorized Signatory*

If you would like a copy of your submission sent to you, please provide an email address in the field below.

If you experience any issues while submitting the form, please contact Master Data Team for assistance.