SH&E Standard Operating Procedure - North America

S3NA-213-FM Subcontractor SH&E Evaluation

INSTRUCTIONS TO SUBCONTRACTOR/ORGANIZATION COMPLETING THE AECOM SUBCONTRACTOR SH&E EVALUATION

1. Complete the administrative information related to your organization (Company name, address, etc.) 2. List the service(s) to be performed for AECOM by your organization (direct hire or own forces only, not subcontracted). Examples include (but are not limited to): a. Subsurface drilling b. Excavation operations c. Surveying d. Construction/renovation/clean-construction operations e. Demolition f. Well abandonment g. Electrical system installation h. HAZWOPER 3. List the Experience Modification Rate (EMR) for your organization (entire company, not a local office, division, subsidiary, or joint venture) from the past three years. This information can be obtained from your organizations Workers Compensation Insurance Carrier. If your organizations EMR is greater than 1.0, an explanation must be provided in the appropriate space provided. NOTE: EMR is separate from the Experience Modification Factor (EMF) also provided by your Workers Compensation Insurance Carrier. EMR is a whole number, while EMF is a percentage. 4. Provide the applicable injury and illness data for your organization from the past three years in the table provided. Using the formulas included in the table, calculate the requested Recordable Case Frequency Rate (e.g., Recordable Incident Rate or RIR). If your company has less than ten employees, you are not required to maintain this information according to Title 29 of the Code of Federal Regulations (CFR) Part 1904, Section 1, Subsection (a)(1) [29 CFR 1904.1(a)(1)]; however, if your organization does have less than 10 employees, AECOM still requires that you provide the information for rows d) Total Recordable Cases and e) Total Corporate Hours Worked. 5. List any fatalities your organization has incurred during the past three years and for each occurrence please provide the following information (Supplemental material may be attached to this questionnaire): a. Location where the fatality occurred b. Cause of the fatality c. What corrective action(s) your organization has taken as a result of the fatality 6. List and describe any SERIOUS, REPEAT, WILLFUL, or CRIMINAL citations issued to your organization by a regulatory authority (e.g., OSHA, OH&S, Environment) (Supplemental information related to the specific citation(s) may be attached to the questionnaire). 7. After reading the Compliance Statement on page 3, list the name and phone number of the representative from your organization who completed the questionnaire, sign the questionnaire, and write in the date the questionnaire was completed. By signing the questionnaire, the representative states that they have truthfully answered all questions, that all of the information provided is accurate, and that if selected by AECOM, your organization shall adhere to the requirements identified in the Compliance Statement. 8. Based on the types of services to be provided by the contractor, other qualification criteria is recommended for use including but not limited to: a. Identity and qualifications of site safety officer b. Training qualification(s) of employees (e.g., certifications, permits, etc.)

S3NA-213-FM Subcontractor Evaluation Form Revision 0 01 October 2010

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SH&E Standard Operating Procedure - North America

Should the subcontractor have any questions regarding this evaluation, please contact the AECOM Project Manager or representative. Company Name: Address: City: Has company name changed in the last 3 years: If YES, please provide previous operating name(s): List Service(s) to be provided: Yes No State/Province: Date:

1. Experience Modification Rates a) List your firms Experience Modification Rate (EMR) for the three (3) most recent years. ( Information is available from your Workers Compensation Insurance Carrier ) Year Experience Modification Rate

b) If your organization does not have an EMR or your EMR is greater than 1.0, please explain why.

2. Please consolidate your injury and illness data for the last three (3) years and complete the following: Data a) b) c) d) e) f) Number of Lost Workday Cases (not days lost) Number of Restricted Workday Cases (not restricted days) Number of Medical Treatment Cases (not including first aid) Total Recordable Cases (a + b + c) Total Corporate Hours Worked (hourly and salaried employees) Recordable Case Frequency Rate (RCFR) ([d x 200,000] / e) Yes No Year Year Year

a) Does your organization have fewer than 10 employees?

Note: If you check Yes, you are required to only complete rows d), e), and f) in the above table. 3. List any fatalities your firm has had in the last three (3) years. Include location, cause, and corrective actions. (Attach supplemental information as required)

S3NA-213-FM Subcontractor Evaluation Form Revision 0 01 October 2010

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PRINTED COPIES ARE UNCONTROLLED. CONTROLLED COPY IS AVAILABLE ON COMPANY INTRANET

SH&E Standard Operating Procedure - North America

4. List any SERIOUS, REPEAT, WILLFUL, or CRIMINAL citations your firm has had in the last three (3) years. Please describe. (Attach supplemental information as required)

5. Do you have a written safety and health manual? Yes No If yes, provide the Table of Contents. If no, please indicate how you confirm that the following are addressed: training, incident reporting and investigation, inspections, hazard assessments, emergency response procedures

6. Do you have any certificates or awards related to SH&E (e.g., OHSAS 18001, COR, etc.)? Yes If yes, please list:

No

Completed by Subcontractor Manager (Print Name):

Completed by (Signature):

Phone Number: Procurement/Safety/Management Use Only Evaluated by (Print Name): Evaluated by (Signature):

Date Completed:

Region

Date:

EMR Rating

RCFR Rating

# of Citations

OVERALL RATING*

*The lowest of the three individual criteria ratings. Evaluator Note: If the organization checked YES to 2.a), they only need to provide the applicable data for rows d) and e) in the table in Section 2, and the evaluator will calculate the RCFRs by applying the formula found in row f). If the organization checked NO, then they must provide all requested data to be considered compliant

S3NA-213-FM Subcontractor Evaluation Form Revision 0 01 October 2010

3 of 4

PRINTED COPIES ARE UNCONTROLLED. CONTROLLED COPY IS AVAILABLE ON COMPANY INTRANET

SH&E Standard Operating Procedure - North America

S3NA-213-FM Subcontractor Evaluation Form Revision 0 01 October 2010

4 of 4

PRINTED COPIES ARE UNCONTROLLED. CONTROLLED COPY IS AVAILABLE ON COMPANY INTRANET