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

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Preisdent/Owner

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*

Rumford

Biron

Fairmont

Old Town

Chicago

Dayton

Sturtevant

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Contractor Type

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Today's Date*

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Please attach an organizational chart of the company detailing the employees and their titles.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Contractor Safety Record

Please state your Current Insurance Carrier

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2019 Insurance Carrier (if different from current)

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2018 Insurance Carrier (if different from current)

EMR for 2018

TCIR for 2018

LTIR for 2018

Fatalities for 2018

EMR for 2019

TCIR for 2019

LTIR for 2019

Fatalities for 2019

EMR for 2020

TCIR for 2020

LTIR for 2020

Fatalities for 2020

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Worker's Comp Experience Modification Rate (EMR) and insurance carrier for 2018

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Worker's Comp Experience Modification Rate (EMR) and insurance carrier for 2019

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Worker's Comp Experience Modification Rate (EMR) and insurance carrier for 2020

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: 50 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*

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Safety Reporting

How often are incident reports or accident summaries sent to the following? Please note that the immediate reporting of accidents onsite any ND Paper facility is required.

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ND Paper (only for accidents onsite)

Once a month

Once a quarter

Once every 6 months

Once a year

Never

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Company President

Once a month

Once a quarter

Once every 6 months

Once a year

Never

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Field Supervision

Once a month

Once a quarter

Once every 6 months

Once a year

Never

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: 50 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: 50 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: 50 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*

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.