xx承包商資格預審調(diào)查表（PQQ）

1、xx糧油SHGOC承包商資格預審調(diào)查表（PQQ）Contractors Pre-Qualification Questionaire (PQQ)通用信息 GENERAL INFORMATION1.公司名稱Company Name:xx公司電話Telephone:xx傳真Fax:xx街道地址Street Address: xx市xx郵寄地址Mailing Address: xxxx網(wǎng)址 Web site:聯(lián)系人Contact Person:xx電子郵件e-mail:xx電話 Telephone:xx 傳真Fax:xx2. 管理人員人數(shù)Officers number：420人總經(jīng)理/總裁Presi

2、dent:xx 3. 貴機構在目前商號下經(jīng)營已有多少年？ How many years has your organization been in business under your present firm name?60年4. 母公司名稱Parent Company Name: xx公司市City:xx市省Province:xx省郵政編碼Postal Code:xx子公司Subsidiaries:5. 何時以來處于目前管理下（日期）Under Current Management Since (Date):19976. 保險信息聯(lián)系人Contact for Insurance Info

3、rmation:xx職務Title: 高級客戶經(jīng)理電話Telephone:xx傳真Fax:xx7. 保險公司 Insurance Carrier(s): 平安保險股份有限公司xx分公司名稱Name保險覆蓋類型Type of Coverage電話Telephone平安保險股份有限公司xx分公司團體人身意外險及一切險xx8. 貴公司對勞工賠償保險是否勞動保險？ 意外傷害險？是Yes 否No 是Yes 否No 9. 招標聯(lián)系人Contact for Requesting Bids:xx職務Title:副總經(jīng)理電話Telephone: xx傳真Fax:xx10. PQQ填寫人 PQQ Complete

4、d By: xx職務Title: 科長電話Telephone:xx傳真Fax:xx組織機構ORGANIZATION11. 企業(yè)類型Form of Business: 全資擁有Sole Owner 合營公司Partnership 股份公司Corporation 12. A. 描述提供的服務Describe Services Performed: 施工Construction 施工設計Construction Design 原始設備制造商和安裝商Original Equipment Manufacturer and Installer 原始設備制造商和維修商Original Equipment M

5、anufacturer and Maintenance 服務工作（例如保安、文秘服務等等）Service work (e.g. janitorial, clerical, etc.)維修Maintenance人力資源Manpower and Resource專業(yè)維修Specialty Maintenance大修Turnaround 工程Engineering其它Other13.描述提供的附加服務Describe Additional Services Performed:14.A.貴公司通常雇用的是Do you normally employ? 勞動合同員工 Personnel 勞務人員Non

6、-Personnel 租借人員Leased Personnel B.過去三年平均員工數(shù)量 Average number of employees for last 3 years ：825人C.目前員工總數(shù)：約800人15.過去三年業(yè)務金額總量Annual Dollar Volume for the Past Three Years:USDYR$YR$YR$16.過去三年期間的最大工程Largest Job During the Last 3 Years: ¥30079.00萬元17.正在進行的重大工程Major jobs in progress:客戶地點 Customer/Loca

7、tion工作類型Type of Work規(guī)模 Size$M客戶聯(lián)系人Customer Contact電話Telephonexx市工藝、設備安裝調(diào)試1098.00萬元xxxx18.過去三年中完成的重大工程Major jobs completed in the past three years:客戶地點 Customer/Location工作類型Type of Work規(guī)模Size$M客戶聯(lián)系人Customer Contact電話Telephonexx庫二期工藝管線及儲罐安裝30079.00萬元xxxx19.貴公司是否有任何未決的或未執(zhí)行的判決、索賠或訴訟？ Are there any judgm

8、ents, claims or suits pending or outstanding against your company?If yes, please attach details.Yes qNo q如果是，請附解釋。If yes, please attach explanation是Yes 否No 安全和健康績效SAFETY & HEALTH PERFORMANCEYNN/A1傷病數(shù)據(jù) Injury and Illness Data:a.過去三年員工的工作時間（不包括分包商） Employee work hours in last three years excluding

9、 subcontractors)小時年Hours / YearYRYRYR現(xiàn)場Field總共Totalb. 提供過去三（3）年貴公司記錄下列數(shù)據(jù)（不包括分包商）：Provide the following data (excluding subcontractor) using your company records from the past three(3) years:注：（1）數(shù)據(jù)是適用于該地區(qū)或區(qū)域的最佳可用數(shù)據(jù)。Notes: (1) Data should be the best available data applicable to the work in this regi

10、on or area. （2）如果公司沒有計算事故率，可以直接填寫事故數(shù)量。If company doesnt have requirement to calculate incidnet rate, can fill in incident number.YRYRYRNo.RateNo.RateNo.Rate 相關死亡率 Injury related fatality and injury number工傷死亡率 =（傷害數(shù) x 200,000）員工總時間Rate = # of Injuries x 200,000)/ Total Employee Hours000000涉及 損工傷害率Lo

11、st workday case injuries involving days away from work.損工傷害率 =（傷害數(shù) x 200,000）員工總時間Rate = # of Injuries x 200,000)/ Total Employee Hours000000須報告的總傷害率 (所有需要到醫(yī)院治療的受傷事故)Total Recordable Injury Rate (All injuries need get treatment from hospital須報告的傷害率 =（傷害數(shù)x 200,000 ）員工總時間Rate = # of Injuries x 200,000

12、)/ Total Employee Hours0000002.過去三年中貴公司是否受過獎勵？Have you received any regulatory citations in the last three years?YNN/Axx省xx工程評為2011年度xx地區(qū)建設工程質(zhì)量年度“五羊杯”獎；xx省xx工程評為2011年度xx優(yōu)良樣板工程；xx市xx工程評為2011年度xx優(yōu)良樣板工程。安全健康管理信息SAFETY & HEALTH MANAGEMENT INFORMATION3. 安全健康管理公司中最高級別的安全健康專業(yè)人員Safety and Health Managem

13、entHighest ranking safety/health professional in the company: 注冊安全工程師 職務Title: 項目經(jīng)理聯(lián)系人Contact:xx電話Telephone: xx傳真Fax: xxYNN/A a. 貴公司是否具有或提供下列人員？ Do you have or provide:a.專職安全健康總監(jiān)Full time Safety/Health Director是Yes 否No b.專職現(xiàn)場安全健康主管Full time Site Safety/Health (S&H) Supervisor 是Yes 否No c.專職現(xiàn)場安全健康

14、承包商協(xié)調(diào)人Full time Site Safety/Health Contractor Supervisor是Yes 否No b.貴公司是否有書面安全健康管理體系？Do you have a written Safety and Health Program? 是Yes 否No c.體系中是否有出下列要素？Does the program address the following key elements?1. 管理層承諾和預期Management commitment and expectations是Yes 否No 2. 員工參與Employee participation是Yes

15、否No 3. 經(jīng)理、主管和員工的責任和職責Accountabilities and responsibilities for managers, 是Yes 否No supervisors, and employees4. 滿足安全健康要求的資源Resources for meeting safety & health requirements是Yes 否No 5. 定期評估所有員工的安全健康績效Periodic safety and health performance appraisals是Yes 否No for all employees6. 安全獎懲制度Safety Recogn

16、ition Program 是Yes 否No 7. 危害識別和控制Hazard recognition and control是Yes 否No d.制度是否符合法律對貴公司/責任人的責任要求Does the program satisfy your responsibility under the law for:1. 確保貴公司員工遵守的安全規(guī)章制度？Ensuring your employees follow the safety rules of是Yes 否No the facility?2. 承包商在作業(yè)中發(fā)現(xiàn)的任何危險通知給業(yè)主？Advising owner of any uniqu

17、e hazards presented by是Yes 否No the contractors work, and of any hazards found by the contractor?安全健康慣例和程序SAFETY & HEALTH PRACTICES & PROCEDURESYNN/A4.體系是否包括安全作業(yè)慣例和程序？例如Does the program include work practices and procedures such as:a.設備上鎖掛牌（LOTO）Equipment Lockout and Tagout (LOTO)是Yes 否No 不適用

18、N/A b.入槽/密閉空間作業(yè)Confined Space Entry是Yes 否No 不適用N/A c. 傷害疾病報告記錄Injury & Illness Recording是Yes 否No 不適用N/A d. 墜落防護Fall Protection 是Yes 否No 不適用N/A e. 個人防護裝備Personal Protective Equipment是Yes 否No 不適用N/A f.便攜式電動工具Portable Electrical/Power Tools是Yes 否No 不適用N/A g.車輛安全Vehicle Safety是Yes 否No 不適用N/A h.壓縮氣體鋼

19、瓶Compressed Gas Cylinders是Yes 否No 不適用N/A i.電氣設備接地保證Electrical Equipment Grounding Assurance是Yes 否No 不適用N/A j. 動力工業(yè)車輛（起重機，叉車，JLG等）Powered Industrial Vehicles 是Yes 否No 不適用N/A (Cranes, Forklifts, JLGs, etc.)k.內(nèi)務整理Housekeeping是Yes 否No 不適用N/A l.事故意外報告Accident/Incident Reporting是Yes 否No 不適用N/A m.不安全條件或隱患報

20、告Unsafe Condition or hazard Reporting是Yes 否No 不適用N/A n.應急準備情況，包括疏散計劃Emergency Preparedness, including evacuation plan是Yes 否No 不適用N/A o.廢料處置Waste Disposal是Yes 否No 不適用N/A p. 材料裝卸和人工吊裝技術Material Handling & Manual Lifting Techniques是Yes 否No 不適用N/A YNN/A5.貴公司是否具備下列書面S&H程序或制度？Do you have written S

21、&H programs for the following:a.新員工安全崗前培訓Safety Orientation Training for new employees是Yes 否No b. 呼吸防護Respiratory Protection 是Yes 否No 不適用N/A 適用時，員工是否：Where applicable, have employees been:接受過培訓Trained是Yes 否No 接受過體格檢查Fit tested是Yes 否No 獲得醫(yī)療核準Medically approved是Yes 否No c. 危險品危害溝通Hazard Communicati

22、on 是Yes 否No 員工是否經(jīng)過培訓Have employees been trained是Yes 否No d.學徒和技工培訓Aprentiship and Craftsman Training 是Yes 否No e. 事故 調(diào)查和報告Incident Investigation and Reporting 是Yes 否No f. 現(xiàn)場安全檢查和措施跟蹤制度和要求Site safety inspection and follow up procedure是Yes 否No YNN/A6.醫(yī)療 Medicala.貴公司進行過下列體檢？Do you conduct medical examina

23、tions for:錄用前Pre-placement 是Yes 否No 不適用N/A 錄用前工作能力Preplacement Job Capability是Yes 否No 不適用N/A 聽力功能（聽力圖）Hearing Function (Audiograms)是Yes 否No 不適用N/A 肺Pulmonary是Yes 否No 不適用N/A 呼吸Respiratory是Yes 否No 不適用N/A b. 描述貴公司將如何為現(xiàn)場員工提供急救和其它醫(yī)療服務Describe how you will provide first aid and other medical services for

24、your employeeswhile on-site. 說明由誰提供該服務：項目部設置臨時處置醫(yī)務室，一般不損失工時的傷害由現(xiàn)場醫(yī)務室進行處理，現(xiàn)場醫(yī)務室不能處理的傷害及時送就近醫(yī)院或傳呼120進行救援處理。Specify who will provide this service: c. 貴公司員工是否經(jīng)過急救和CPR培訓？Do you have personnel trained to perform first aid and CPR?是Yes 否No YNN/A7.貴公司是否為下列人員開過現(xiàn)場安全健康會？Do you hold site safety and health meeti

25、ngs for:現(xiàn)場主管/經(jīng)理Field Supervisors/managers是Yes 否No 頻率Frequency：項目開工前1次員工Employees是Yes 否No 頻率Frequency：項目開工前1次，后每天1次新聘員工New Hires是Yes 否No 頻率Frequency：入場前1次，后每天1次分包商Subcontractors是Yes 否No 頻率Frequency：入場前1次，后每天1次安全健康會議是否有記錄？Are the safety and health meetings documented 是Yes 否No 8.個人防護裝備（PPE）Personal Pro

26、tection Equipment (PPE)a. 是否為員工提供了適用的PPE ？YNN/AIs applicable PPE provided for employees?是Yes 否No 眼睛和面部防護Eye & Face Protection是Yes 否No 頭部防護Head Protection是Yes 否No 腳部防護Foot Protection是Yes 否No 聽力防護Hearing Protection是Yes 否No 手部防護Hand Protection是Yes 否No 工作服（例如FRC等）Clothing (e.g. FRC, etc)是Yes 否No 防墜落

27、保護或全身式安全帶 Personal fall protection equipment 是Yes 否No or full budy safety harness YNN/A9.設備和材料 Equipment and Materials:a.貴公司是否有對購置的材料和設備建立適用的健康、安全和環(huán)境規(guī)格的要求？Do you have a requirementfor establishing applicable health,是Yes 否No 不適用N/A safety, and environmental specifications for acquisition of materials

28、 and equipment?b.貴公司是否按照監(jiān)管要求對操作設備（如起重機，叉車，JLG等）進行檢驗？Do you conduct inspections on operating equipment 是Yes 否No 不適用N/A (e.g., cranes, forklifts, man liftss) in compliance with regulatory requirements?b. 貴公司是否按照制造商要求維護操作設備？Do you maintain operating equipment in compliance with是Yes 否No 不適用N/A manufactu

29、rers requirements?d. 貴公司是否保存操作設備的適用檢驗和維修認證記錄？Do you maintain the applicable inspection and maintenance是Yes 否No 不適用N/A certification records for operating equipment?10.分包商 Subcontractors貴公司是否使用分包商嗎？YNN/ADo you use subcontractors?是Yes 否No （如果否，跳過下面4個問題問題） (If No, skip to question from a to d)a. 貴公司在選擇

30、分包商時是否使用安全健康績效準則？Do you use safety and health performance criteria in是Yes 否No 不適用N/A selection of subcontractors?b. 貴公司是否把評價分包商符合適用健康安全要求的能力作為選擇過程的一部分？Do you evaluate the ability of subcontractors to 是Yes 否No 不適用N/A comply with applicable health and safety requirementsas part of the selection proces

31、s?c. 貴公司分包商是否具有書面安全健康制度?Do your subcontractors have a written Safety & Health是Yes 否No 不適用N/A Program?d. 貴公司是否讓分包商參加下列活動：Do you include your subcontractors in:安全健康崗前培訓Safety & Health Orientation 是Yes 否No 不適用N/A 安全健康會議Safety & Health Meeting是Yes 否No 不適用N/A 檢查Inspections是Yes 否No 不適用N/A 評審Au

32、dits是Yes 否No 不適用N/A YNN/A11.檢查和審計 Inspections and Auditsa.貴公司是否進行安全健康檢查？Do you conduct safety and health inspections?是Yes 否No b.貴公司是否進行安全健康制度評審？Do you conduct safety and health program audits?是Yes 否No c. 是否提供過去3年現(xiàn)場檢查記錄樣本（至少5份）？Could they provide at least 5 site safety inspection report in past 3 yea

33、rs?是Yes 否No d. 是否提供過去3年檢查發(fā)現(xiàn)問題的制定行動項Action plan of corrections in past 3 years?是Yes 否No e. 是否有整改記錄？Are corrections of deficiencies documented?是Yes 否No f. 是否提供過去3年現(xiàn)場安全審計樣本（至少2份）？Could they provide at least 2 safety audit report ?是Yes 否No g. 是否提供過去3年現(xiàn)場安全審計糾正措施？是Yes 否No 安全健康培訓SAFETY & HEALTH TRAININ

34、GYNN/A12.安全培訓 Safety Traininga.貴公司是否了解法規(guī)要求的安全培訓？Do you know the regulatory safety training是Yes 否No b. 貴公司員工是否接受過必需的安全培訓并有記錄？Have your employees received the required safety and requirements training for your employees?是Yes 否No c. 貴公司培訓內(nèi)容是否適用于相關崗位員工？Does the training material suit for employees?是Yes

35、否No d. 貴公司安全培訓人員具備相應資質(zhì)Is the trainer with certain qualificaiton?是Yes 否No 貴公司是否具有針對主管的相關安全健康培訓制度？Do you have a specific safety and health training program是Yes 否No for supervisors?e. 是否所有員工接受了相關作業(yè)制度培訓并能安全地執(zhí)行工作？Are all employees trained in the work practices needed 是Yes 否No to safely perform his/her jo

36、b?g.是否已將已知的潛在火災、爆炸或釋放毒性危險品的情況和應急行動計劃的程序和適用措施告知與該工作相關的每位員工？Is each employee instructed in the kown potential是Yes 否No of fire, explosion, or toxic release hazards related tohis/her job, the process and the applicable provisionsof the emergency action plan?以下填寫能負責保證本文件準確性的公司高管人員的姓名和職務：Fill in below Nam

37、e & Title of Company Officer responsible for assuring the accuracy of this document:職務Title 質(zhì)安科科長 姓名Name xx 日期Date 2015-02-03 信息提交INFORMATION SUBMITTAL所有承包商都需要詳盡填寫資格預審調(diào)查表（PQQ）。在主承包商之下工作的一次性服務承包商或分包商必須提供至少一份PQQ表供審查。但是，希望進入現(xiàn)場核準承包商名單（核準三年）的承包商還必須提供下列檢查項：Thorough completion of the Pre-Qualification

38、Questionaire (PQQ) is required of all Contractors (*). One time service contractors or sub-contractors working under a primary contractor must submit at a minimum the PQQ form for review. However, Contractors desiring to get on the Sites (3 year approval) list of approved contractors must also provi

39、de the following checked items: 勞工賠償文件（來自貴公司的保險人）Workers Compensation documentation (from your insurance carrier)保險證書Insurance Certificate(s)傷病指數(shù)和文件（過去三年）Injury/Illness Index and documentation (Past 3 Years)安全健康制度Safety & Health Program危險品危害通報程序Hazard Communication Program 呼吸防護制度Respiratory Prot

40、ection Program 事故意外調(diào)查程序Accident/Incident Investigation Procedure 不安全條件報告程序Unsafe Condition Reporting Procedure 安全健康檢查評審程序和表格Safety & Health Inspection / Audit Procedure & Form 崗前安全健康培訓（大綱）Safety & Health Orientation (Outline) 安全健康培訓制度（大綱）及培訓記錄示例Safety & Health Training Program (Outli

41、ne) with examples of training records 組織機構圖Organization Chart貴公司為在該設施中可用于作業(yè)的主要設備清單（如起重機、JLG、叉車等）List of major equipment (e.g., cranes, man-lifts, forklifts, etc) your company has available for work at this facility. * 在承包商核準程序期間，xx可能要求審查其它相關信息，例如記錄和符合性證據(jù)。SHGOC may request a review of other pertinent

42、 information such as records and evidence of compliance during the Contractor approval process.PQQ評估- 僅供xx糧油使用 - PQQ EVALUATION- SHGOC USE ONLY -不需填寫 僅供業(yè)主使用DO NOT FILL OUT - OWNER USE ONLY承包商為：Contractor is:A級 獲準（得分90 100），該承包商將被列入xx優(yōu)選承包商名單。A Approved (score 90 100), the contractor will be on the pr

43、eferred SHGOC Contractor list.B級 獲準（得分80 89.99），該承包商將得到xx評估結(jié)果并被要求解決安全制度問題。該承包商將被列入xx優(yōu)選承包商名單。B Approved (score 80 89.99) the contractor will have access to SHGOC evaluation results and asked to address Safety programs issues. The contractor will be placed on the SHGOC preferred contractor list.C級 可能獲

44、準（得分70 79.99），要求現(xiàn)場主管核準*特定工作。承包商將得到xx評估結(jié)果。除非問題得到解決并符合本SWP的要求，否則該承包商將不被列入xx優(yōu)選承包商名單。C Contingent approval (score 70 79.99), requires Site Director approval* for a specific job. The contractor will have access to SHGOC evaluation results. The contractor shall Not be placed on the SHGOC preferred contractor list unless issues are addressed and in accordance with this SWP. D 級 可能要制訂書面