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<br /> <br /> <br />APPENDIX A <br />S FF!'T`V O TE TONNAIRF ( COn' t . ) <br />q) Drugs and Controlled Substances <br />r) Lock, Tag and Try <br />s) Hot Work/Safety Work Permits <br />t) Emergency Response Planning <br />u) Department of Transportation/ Pipeline <br />Safety <br />Yes No N/A <br />1 <br />1 <br />1 <br /> <br />CJ <br /> <br />12. Does your firm hold refresher "stair step" or "tailgate" <br />safety and health meetings? <br />Yes No <br />How often? a) Weekly b) Bi-weekly c) Monthly <br />d) Less often, as needed <br />13. Does your firm periodically conduct specialized safety and <br />training for supervisors? Yes No _ <br />' 14. Does your firm require periodic physical examinations for <br />personnel performing hazardous activities or requiring the use <br />' of respiratory protective devices? Yes No <br />15. Other information pertaining to the above may be attached <br />' (i.e., informal programs, procedures, work history, experience <br />and qualifications). <br />16. Audit Authorization: Ia the event a contract is awarded to <br />the undersigned, it is agreed that information concerning <br />responses made is this OSY Contractor Safety Questionnaire may <br />' be audited by representatives of OSY, and such information <br />sill be retained by the undersigned for a minimum period of <br />' three (3) years from the date hereof. <br />Person Completing Safety Information Form: <br />Name- <br />Position: <br />A-4 <br />1 <br />