General Electric Global Research

Niskayuna, New York

GEGR Contractor Health & Safety Pre-Authorization Form

Appendix A
GEGR ENVIRONMENTAL, HEALTH AND SAFETY EVALUATION
(GEGR EHS USE ONLY)
Contractor Qualification Review: Approved
Class Two
Date:
EHS Review by:

Not Approved Class One

Comments:

CONTRACTOR COMPANY PROFILE

Company
Name:
Street Address:

Mailing
Address:

Telephone #:
Total #
Employees:
E-mail
Address*:

Fax #:
NAICS/SIC
Code:

CONTRACTOR ORGANIZATION
Form of Business:
Parent Company
Name:
Parent Company
Address:
Subsidiari
es

Sole Owner

Partnership

Check () services to be performed:

Abatement
Equipment Manufacturer
Construction
Equipment Inspection
Construction Design
Equipment Installation
Consulting
Equipment Maintenance
Engineering
General Maintenance
Environmental
Services

Corporation

Pick-Up / Delivery
Service Work
Supplier
Technical Support
Other
:

Manpower and Resource

Specifically describe services

performed:
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General Electric Global Research

Niskayuna, New York
GE Global Research Project Coordinator contact name:
Will your company be working on site as a Sub-Contractor?
If yes:
Name of General Contractor
Company:
Contact Name:

Yes

No

Telephone
#:

GE Global Research Sourcing Contact name:

CONTRACTOR SAFETY STAFF

Does your company have a Safety Department?
Does your company have a full-time safety Manager?
Designated Contractor Safety Rep(s)
Name
(CSR) *Must be onsite at all times when
:
work is being performed
E-mail:

Telephone
#:

Whom may we contact regarding questions

Name
on this Pre-Authorization Form?
:
E-mail:
Telephone #:
Your Company achieved OSHA VPP STAR status?
Yes

No

WORKERS COMPENSATION
List your Workers Compensation Experience Modification Rate (EMR) for the past three years:
Year
EMR:
Year:
EMR:
Year:
EMR:
:
Current Insurance Agent:
*** NOTE: Attach a letter from your insurance broker verifying EMR for past three
years.

SAFETY PERFORMANCE

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General Electric Global Research

Niskayuna, New York

Provide
information
on your
OSHA recordable
for the pastYear:
THREE years. ThisYear:
is obtained from the
From the
OSHA 300A
Logs:
Year:
OSHA 300A
Logs.
Refer
to
OSHAs
Record
Keeping
Guidelines
for
more
details. If less than
# of Hours worked:
10 employee and
you
are
not
required
to
maintain
an
OSHA
300
log,
you
must provide
# of fatalities:
Experience
Factor (EMF) for each of the last three years from your insurance
# of casesModification
with days away
carrier.
from work:
YOU MUST COMPLETE THE TABLE BELOW AND SUBMIT THE
# of recordable injuries and
BACKUP DOCUMENTS. illnesses:
Recordable Incident Rate *
(RIR):
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General Electric Global Research

Niskayuna, New York
Lost Time Incident Rate **
(LTIR):
* RIR Formula: Total # recordable cases x 200,000
Total Hours Worked
** LTIR Formula: # lost work day cases x 200,000
Total Hours Worked
Attach copies of your OSHA 300A Logs for the past three (3) years. Remember please do NOT
provide the names of the injured employees so as to protect their privacy.
YOU MUST COMPLETE THE TABLE AND SUBMIT THE
BACKUP DOCUMENTS.

OSHA INSPECTIONS / CITATIONS

Has the company received a citation from a regulatory agency (OSHA, EPA) within the past five
years? Yes

No

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General Electric Global Research

Niskayuna, New York

Has
there been
a work-related
deathissued,
or multiple
hospitalizations
within
the
past five
years?
*** NOTE:
If citations
have been
please
attach copies
and
provide
an
explanation.
(If Yes, Please describe the
fatality)
CONTRACTOR
SAFETY PROGRAM
Does your company have a written EHS Program?
Yes
No
*** Note: If no program exists, a Task Hazard Analysis shall be developed prior to
conducting work on site.
If yes, does your Health and Safety Program have the following:
Yes
No
Documented Environment, Health and Safety procedures?
Yes
No
Are designated roles and responsibilities assigned for health and safety?
Yes
No
Accountabilities and responsibilities for Supervisors?
Yes
No
Accountabilities and responsibilities for all employees?
Yes
No
Resources for meeting safety and health requirements?
Yes
No
A disciplinary policy with regard to safety violations?
Yes
No
Hazard communication program (HazCom)?
Yes
No
Safety orientation training for new employee hires?
Yes
No
Regulatory Required Safety training provided to employees?
Yes
No
Personal Protective Equipment (PPE) Program?
Yes
No
Medical surveillance program?
Yes
No
Are safety meetings (Tool Box Talks) provided on the job site?
Yes
No
Electrical safety Program (NFPA 70-E) / Utilize GFCI
Yes
No
Power Tool Safety Program (GFCI Use, Inspections, Extension Cords, etc.)
Yes
No
Accident Reporting / Incident investigations?
Yes
No
Are job sites / work areas periodically inspected?
Note: Requested documents as part of this qualification form may be submitted on CD or DVD format

ELECTRICAL WORK
Yes
Will your company be performing work on or near exposed energized components
greater than 50 volts (including troubleshooting, testing, diagnostics, etc). If yes
Yes
Do you consider your employees electrically qualified
Yes
Have the employees you consider qualified completed NFPA 70E Training
Yes
Does your company have a Flame Resistant (FR) clothing program
Yes
Does your company provide your employees with electrical Personal
Protective Equipment
Yes
Does your company provide employees with electrically insulated tools
Note: If your company will be performing work on or near exposed energized
components, training documentation, and equipment testing certificates must
submitted with this Contractor Authorization Form

No
No
No
No
No
No
be

LOCKOUT / TAGOUT PROGRAM

Will your company perform work on systems where hazardous energy will need
to be de-energized. And or controlled If yes:
Does your company have a written LOTO program?
Are your employees trained in Authorized LOTO procedures?
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Yes

No

Yes
Yes

No
No

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General Electric Global Research

Niskayuna, New York

Are your Authorized employees issued locks designated by the employer?

Yes
No
*** NOTE: If your company performs Lockout / Tagout, a written Lockout / Tagout
program MUST be submitted along with this Contractor Authorization Form.

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Niskayuna, New York
CONFINED SPACE PROGRAM
Will your company be working in a confined space as defined by 29CFR1910.146 ? Yes
No
If yes:
Yes
No
Does your company have a written Confined Space Program?
Yes
No
Are employees trained in first aid, CPR, and non-entry rescue techniques?
Yes
No
Are employees trained in entrant, attendant, & entry supervisor techniques?
Yes
No
*** NOTE: If your company performs Confined Space Procedures, a written Confined
Space Program MUST be submitted along with this Contractor Authorization Form.

HOT WORK PROGRAM

Will your company perform Hot Work Procedures on site?
If yes:
Does your company have a written Hot Work Program?
Will your company utilize compressed gas cylinders to perform Hot Work?
Are your employees trained in fire watch responsibilities?
Are your employees trained in fire extinguisher use and techniques?

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

RESPIRATORY PROGRAM
Will your company personnel be required to wear Respiratory Protection while
Yes
No
working on site?
If yes:
Yes
No
Does your company have a Respiratory Protection Program?
Yes
No
Are your employees medically evaluated to wear respirators?
Yes
No
Are your employees trained on respirator usage (cleaning, storage, and
Yes
No
Are your employees fit-tested on an annual or more frequent basis?
Yes
No
*** NOTE: If your company performs work that requires respiratory protection, a
written Respiratory Protection Program MUST be submitted along with this Contractor
Authorization Form.

EXCAVATIONS
Will your company conduct Excavations greater than four (4) feet while working
Yes
No
on site?
If yes:
Yes
No
Does your company have a written Excavation Procedure?
Yes
No
Does your company typically uses trench boxes or sloping/benching as an
Yes
No
employee protection from cave-ins.
Are your employees trained in excavation and trenching safety?
Yes
No
Do you have a competent person, as defined by 29 CFR 1926.650?
*** NOTE: If your company performs Excavations greater than four (4) feet, an
Excavation Competent Person designated by the company MUST be present and on site
if personnel will be entering the excavation. Proof of qualification shall be submitted
along with this Contractor Authorization Form.

HAZARDOUS MATERIALS
Will your company work with Hazardous Materials on site?
Yes
No
If yes:
Yes
No
Does your company have a HAZWOPER training program?
Yes
No
Do you have a medical surveillance program based on the materials you will be Yes
No
working with
*** NOTE: If your company will be performing activities covered under 29CFR1910.120,
proof of current training shall be submitted along with this Contractor Authorization
form.
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Niskayuna, New York
ASBESTOS
Will your company work with Asbestos on site? If yes:
Yes
No
Does your company have a license to perform asbestos work in New York
Yes
No
State?
Are your employees trained and hold appropriate licenses to work with
Yes
No
asbestos In New York?
Does your company have a written asbestos removal procedure?
Yes
No
Do you have a medical surveillance program?
Yes
No
Has your company received any citations in the last 3 years?
Yes
No
*** NOTE: If citations have been issued, please attach copies and provide an
explanation. Copies of current license to perform asbestos work in New York state must
be provided prior to performing work.

EQUIPMENT OPERATOR SAFETY

Will you be using forklifts, cranes, aerial lifts, manlifts, scissor lifts or other
vehicles on site?
If using forklifts, do your employees hold current certification?
If using cranes on site, do you have certified crane operators?
If using aerial lifts, manlifts, scissor lifts, or similar, have your employees been
trained on the operation of these units? Contractor has been trained

Yes

No

Yes
Yes
Yes

No
No
No

EQUIPMENT SAFETY DECLARATION

Will your company be bringing company owned/leased/rented equipment onto
Yes
GEGR Property?
Does your company have a daily equipment inspection/check program?
Yes
All equipment /vehicles shall have current state inspection, registration, load test etc.
All equipment shall be maintained in accordance with manufacturer specification
All equipment shall be in good working order with no visible fluid leaks

No
No

CRAFT TRAINING
Does your company ensure that skilled craft workers are certified?
List crafts that have been certified (i.e. welder, electrician):

SUB-CONTRACTOR

Will you hire sub-contractors to assist in any on-site projects

If yes:
Do you use Environmental, Health, & Safety performance in your selection of subcontractors? See attached letter
Do you evaluate the ability of sub-contractors to comply with your applicable
Health and Safety requirements, as well as local, state, and federal regulations,
as part of your selection process? See attached letter
Do you require sub-contractors to have their own written Safety & Health
Programs?
Do you include your sub-contractors in:
Safety & Health Orientation?
Safety & Health Meetings?
Safety & Health Inspections?
Safety & Health Audits?
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Yes
Yes

No
No

Yes
Yes
Yes

No
No
No

Yes

No

Yes

No

Yes
Yes
Yes

No
No
No

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General Electric Global Research

Niskayuna, New York
*** Note: All Subcontractors must complete a Pre-Authorization Form and submit to
GEGR EHS for review and approval prior to beginning work.

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Niskayuna, New York
SAFETY TRAINING
All employees that may work at the GE Global Research Facility shall attend the GEGR
safety training. All Contractor and Subcontractor personnel must attend the on site
training prior to beginning work and at least annually thereafter. If you have
questions, contact the Contractor Safety Manager at (518) 387-4208.
Approximate number of employees that will require orientation:
Will any employee require special accommodations (language, literacy, hearing impairment, etc.)?
Yes No
If yes, contact the Contractor Safety Manager for special arrangement PRIOR to orientation.

CERTIFICATION OF PRE-QUALIFICATION INFORMATION

I certify that the above information is correct. I understand that any false information listed on
this form could disqualify my company from being approved. I have also enclosed a copy of all
requested documentation. My company agrees to follow all applicable regulatory standards and
site procedures, as outlined in the GE Global Research Contractor EHS Program.
Signature
:
Print Name:

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Niskayuna, New York

Checklist for Pre-Authorization Information

As indicated in the Pre-Authorization Form, the following items must be
included in order for it to be processed.
Letter from your Insurance Broker verifying your EMR rate for the last 3 years.
Copies of OSHA Log Summaries for the past 3 years. Copies of your companys Workers
Compensation Loss Run Reports may be included instead.
Copy of your companys Current Liability Insurance Certificate.
Copies of any OSHA citations within the past 3 years. Include an explanation for the citations.
Copy of your companys Health and Safety Program, and requested EHS submittals
Copy of your companys employee training records as requested.

Please forward to:

Randy M Stachowicz, CSP
Contractor Safety Manager
One Research Circle
Niskuyna, New York 12309
Phone: 518-387-4208 (518-951-5309 cell)
Fax: 518-387-5082
e-mail: stachowi@ge.com

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Niskayuna, New York
CERTIFICATE OF INSURANCE INFORMATION
All Contractors, Subcontractors and Business Services are required to provide proof of insurance to
GEGR EHS Team. A certificate of insurance is required before any work may be conducted on site.
The limits for the Certificate of Insurance are the following:

General Liability:

General Aggregate: $1,000,000

Products Comp/Ops Aggregate: $1,000,000
Personal & Advertising Aggregate: $1,000,000
Each Occurrence: $1,000,000
Fire Damage: $50,000
Medical Expense $5,000

Automobile Liability:

Combined Single Limit: $1,000,000 or

Bodily Injury (per person): $500,000
Bodily Injury (per Accident): $500,000
Property Damage: $500,000

Workers Compensation:

Statutory Limits: List State

Each Accident: $500,000
Disease (Policy Limit): $500,000
Disease (Each Employee): $500,000

Certificate Holder:
General Electric (many instances)
IDC (for any orders they place)

The certificate of insurance may be supplied to:

General Electric Global Research
Contractor Safety Manager
One Research Circle
Niskuyna, New York 12309
Fax to (518) 378-0000

OR

Include the Certificate of Insurance with this

packet.

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