xx承包商资格预审调查表（PQQ）

1、xx粮油SHGOC承包商资格预审调查表（PQQ）Contractors Pre-Qualification Questionaire (PQQ)通用信息 GENERAL INFORMATION1.公司名称Company Name:xx公司电话Telephone:xx传真Fax:xx街道地址Street Address: xx市xx邮寄地址Mailing Address: xxxx网址 Web site:联系人Contact Person:xx电子邮件e-mail:xx电话 Telephone:xx 传真Fax:xx2. 管理人员人数Officers number：420人总经理/总裁Presi

2、dent:xx 3. 贵机构在目前商号下经营已有多少年？ How many years has your organization been in business under your present firm name?60年4. 母公司名称Parent Company Name: xx公司市City:xx市省Province:xx省邮政编码Postal Code:xx子公司Subsidiaries:5. 何时以来处于目前管理下（日期）Under Current Management Since (Date):19976. 保险信息联系人Contact for Insurance Info

3、rmation:xx职务Title: 高级客户经理电话Telephone:xx传真Fax:xx7. 保险公司 Insurance Carrier(s): 平安保险股份有限公司xx分公司名称Name保险覆盖类型Type of Coverage电话Telephone平安保险股份有限公司xx分公司团体人身意外险及一切险xx8. 贵公司对劳工赔偿保险是否劳动保险？ 意外伤害险？是Yes 否No 是Yes 否No 9. 招标联系人Contact for Requesting Bids:xx职务Title:副总经理电话Telephone: xx传真Fax:xx10. PQQ填写人 PQQ Complete

4、d By: xx职务Title: 科长电话Telephone:xx传真Fax:xx组织机构ORGANIZATION11. 企业类型Form of Business: 全资拥有Sole Owner 合营公司Partnership 股份公司Corporation 12. A. 描述提供的服务Describe Services Performed: 施工Construction 施工设计Construction Design 原始设备制造商和安装商Original Equipment Manufacturer and Installer 原始设备制造商和维修商Original Equipment M

5、anufacturer and Maintenance 服务工作（例如保安、文秘服务等等）Service work (e.g. janitorial, clerical, etc.)维修Maintenance人力资源Manpower and Resource专业维修Specialty Maintenance大修Turnaround 工程Engineering其它Other13.描述提供的附加服务Describe Additional Services Performed:14.A.贵公司通常雇用的是Do you normally employ? 劳动合同员工 Personnel 劳务人员Non

6、-Personnel 租借人员Leased Personnel B.过去三年平均员工数量 Average number of employees for last 3 years ：825人C.目前员工总数：约800人15.过去三年业务金额总量Annual Dollar Volume for the Past Three Years:USDYR$YR$YR$16.过去三年期间的最大工程Largest Job During the Last 3 Years: ¥30079.00万元17.正在进行的重大工程Major jobs in progress:客户地点 Customer/Loca

7、tion工作类型Type of Work规模 Size$M客户联系人Customer Contact电话Telephonexx市工艺、设备安装调试1098.00万元xxxx18.过去三年中完成的重大工程Major jobs completed in the past three years:客户地点 Customer/Location工作类型Type of Work规模Size$M客户联系人Customer Contact电话Telephonexx库二期工艺管线及储罐安装30079.00万元xxxx19.贵公司是否有任何未决的或未执行的判决、索赔或诉讼？ 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，请附解释。If yes, please attach explanation是Yes 否No 安全和健康绩效SAFETY & HEALTH PERFORMANCEYNN/A1伤病数据 Injury and Illness Data:a.过去三年员工的工作时间（不包括分包商） Employee work hours in last three years excluding

9、 subcontractors)小时年Hours / YearYRYRYR现场Field总共Totalb. 提供过去三（3）年贵公司记录下列数据（不包括分包商）：Provide the following data (excluding subcontractor) using your company records from the past three(3) years:注：（1）数据是适用于该地区或区域的最佳可用数据。Notes: (1) Data should be the best available data applicable to the work in this regi

10、on or area. （2）如果公司没有计算事故率，可以直接填写事故数量。If company doesnt have requirement to calculate incidnet rate, can fill in incident number.YRYRYRNo.RateNo.RateNo.Rate 相关死亡率 Injury related fatality and injury number工伤死亡率 =（伤害数 x 200,000）员工总时间Rate = # of Injuries x 200,000)/ Total Employee Hours000000涉及 损工伤害率Lo

11、st workday case injuries involving days away from work.损工伤害率 =（伤害数 x 200,000）员工总时间Rate = # of Injuries x 200,000)/ Total Employee Hours000000须报告的总伤害率 (所有需要到医院治疗的受伤事故)Total Recordable Injury Rate (All injuries need get treatment from hospital须报告的伤害率 =（伤害数x 200,000 ）员工总时间Rate = # of Injuries x 200,000

12、)/ Total Employee Hours0000002.过去三年中贵公司是否受过奖励？Have you received any regulatory citations in the last three years?YNN/Axx省xx工程评为2011年度xx地区建设工程质量年度“五羊杯”奖；xx省xx工程评为2011年度xx优良样板工程；xx市xx工程评为2011年度xx优良样板工程。安全健康管理信息SAFETY & HEALTH MANAGEMENT INFORMATION3. 安全健康管理公司中最高级别的安全健康专业人员Safety and Health Managem

13、entHighest ranking safety/health professional in the company: 注册安全工程师 职务Title: 项目经理联系人Contact:xx电话Telephone: xx传真Fax: xxYNN/A a. 贵公司是否具有或提供下列人员？ Do you have or provide:a.专职安全健康总监Full time Safety/Health Director是Yes 否No b.专职现场安全健康主管Full time Site Safety/Health (S&H) Supervisor 是Yes 否No c.专职现场安全健康

14、承包商协调人Full time Site Safety/Health Contractor Supervisor是Yes 否No b.贵公司是否有书面安全健康管理体系？Do you have a written Safety and Health Program? 是Yes 否No c.体系中是否有出下列要素？Does the program address the following key elements?1. 管理层承诺和预期Management commitment and expectations是Yes 否No 2. 员工参与Employee participation是Yes

15、否No 3. 经理、主管和员工的责任和职责Accountabilities and responsibilities for managers, 是Yes 否No supervisors, and employees4. 满足安全健康要求的资源Resources for meeting safety & health requirements是Yes 否No 5. 定期评估所有员工的安全健康绩效Periodic safety and health performance appraisals是Yes 否No for all employees6. 安全奖惩制度Safety Recogn

16、ition Program 是Yes 否No 7. 危害识别和控制Hazard recognition and control是Yes 否No d.制度是否符合法律对贵公司/责任人的责任要求Does the program satisfy your responsibility under the law for:1. 确保贵公司员工遵守的安全规章制度？Ensuring your employees follow the safety rules of是Yes 否No the facility?2. 承包商在作业中发现的任何危险通知给业主？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?安全健康惯例和程序SAFETY & HEALTH PRACTICES & PROCEDURESYNN/A4.体系是否包括安全作业惯例和程序？例如Does the program include work practices and procedures such as:a.设备上锁挂牌（LOTO）Equipment Lockout and Tagout (LOTO)是Yes 否No 不适用

18、N/A b.入槽/密闭空间作业Confined Space Entry是Yes 否No 不适用N/A c. 伤害疾病报告记录Injury & Illness Recording是Yes 否No 不适用N/A d. 坠落防护Fall Protection 是Yes 否No 不适用N/A e. 个人防护装备Personal Protective Equipment是Yes 否No 不适用N/A f.便携式电动工具Portable Electrical/Power Tools是Yes 否No 不适用N/A g.车辆安全Vehicle Safety是Yes 否No 不适用N/A h.压缩气体钢

19、瓶Compressed Gas Cylinders是Yes 否No 不适用N/A i.电气设备接地保证Electrical Equipment Grounding Assurance是Yes 否No 不适用N/A j. 动力工业车辆（起重机，叉车，JLG等）Powered Industrial Vehicles 是Yes 否No 不适用N/A (Cranes, Forklifts, JLGs, etc.)k.内务整理Housekeeping是Yes 否No 不适用N/A l.事故意外报告Accident/Incident Reporting是Yes 否No 不适用N/A m.不安全条件或隐患报

20、告Unsafe Condition or hazard Reporting是Yes 否No 不适用N/A n.应急准备情况，包括疏散计划Emergency Preparedness, including evacuation plan是Yes 否No 不适用N/A o.废料处置Waste Disposal是Yes 否No 不适用N/A p. 材料装卸和人工吊装技术Material Handling & Manual Lifting Techniques是Yes 否No 不适用N/A YNN/A5.贵公司是否具备下列书面S&H程序或制度？Do you have written S

21、&H programs for the following:a.新员工安全岗前培训Safety Orientation Training for new employees是Yes 否No b. 呼吸防护Respiratory Protection 是Yes 否No 不适用N/A 适用时，员工是否：Where applicable, have employees been:接受过培训Trained是Yes 否No 接受过体格检查Fit tested是Yes 否No 获得医疗核准Medically approved是Yes 否No c. 危险品危害沟通Hazard Communicati

22、on 是Yes 否No 员工是否经过培训Have employees been trained是Yes 否No d.学徒和技工培训Aprentiship and Craftsman Training 是Yes 否No e. 事故 调查和报告Incident Investigation and Reporting 是Yes 否No f. 现场安全检查和措施跟踪制度和要求Site safety inspection and follow up procedure是Yes 否No YNN/A6.医疗 Medicala.贵公司进行过下列体检？Do you conduct medical examina

23、tions for:录用前Pre-placement 是Yes 否No 不适用N/A 录用前工作能力Preplacement Job Capability是Yes 否No 不适用N/A 听力功能（听力图）Hearing Function (Audiograms)是Yes 否No 不适用N/A 肺Pulmonary是Yes 否No 不适用N/A 呼吸Respiratory是Yes 否No 不适用N/A b. 描述贵公司将如何为现场员工提供急救和其它医疗服务Describe how you will provide first aid and other medical services for

24、your employeeswhile on-site. 说明由谁提供该服务：项目部设置临时处置医务室，一般不损失工时的伤害由现场医务室进行处理，现场医务室不能处理的伤害及时送就近医院或传呼120进行救援处理。Specify who will provide this service: c. 贵公司员工是否经过急救和CPR培训？Do you have personnel trained to perform first aid and CPR?是Yes 否No YNN/A7.贵公司是否为下列人员开过现场安全健康会？Do you hold site safety and health meeti

25、ngs for:现场主管/经理Field Supervisors/managers是Yes 否No 频率Frequency：项目开工前1次员工Employees是Yes 否No 频率Frequency：项目开工前1次，后每天1次新聘员工New Hires是Yes 否No 频率Frequency：入场前1次，后每天1次分包商Subcontractors是Yes 否No 频率Frequency：入场前1次，后每天1次安全健康会议是否有记录？Are the safety and health meetings documented 是Yes 否No 8.个人防护装备（PPE）Personal Pro

26、tection Equipment (PPE)a. 是否为员工提供了适用的PPE ？YNN/AIs applicable PPE provided for employees?是Yes 否No 眼睛和面部防护Eye & Face Protection是Yes 否No 头部防护Head Protection是Yes 否No 脚部防护Foot Protection是Yes 否No 听力防护Hearing Protection是Yes 否No 手部防护Hand Protection是Yes 否No 工作服（例如FRC等）Clothing (e.g. FRC, etc)是Yes 否No 防坠落

27、保护或全身式安全带 Personal fall protection equipment 是Yes 否No or full budy safety harness YNN/A9.设备和材料 Equipment and Materials:a.贵公司是否有对购置的材料和设备建立适用的健康、安全和环境规格的要求？Do you have a requirementfor establishing applicable health,是Yes 否No 不适用N/A safety, and environmental specifications for acquisition of materials

28、 and equipment?b.贵公司是否按照监管要求对操作设备（如起重机，叉车，JLG等）进行检验？Do you conduct inspections on operating equipment 是Yes 否No 不适用N/A (e.g., cranes, forklifts, man liftss) in compliance with regulatory requirements?b. 贵公司是否按照制造商要求维护操作设备？Do you maintain operating equipment in compliance with是Yes 否No 不适用N/A manufactu

29、rers requirements?d. 贵公司是否保存操作设备的适用检验和维修认证记录？Do you maintain the applicable inspection and maintenance是Yes 否No 不适用N/A certification records for operating equipment?10.分包商 Subcontractors贵公司是否使用分包商吗？YNN/ADo you use subcontractors?是Yes 否No （如果否，跳过下面4个问题问题） (If No, skip to question from a to d)a. 贵公司在选择

30、分包商时是否使用安全健康绩效准则？Do you use safety and health performance criteria in是Yes 否No 不适用N/A selection of subcontractors?b. 贵公司是否把评价分包商符合适用健康安全要求的能力作为选择过程的一部分？Do you evaluate the ability of subcontractors to 是Yes 否No 不适用N/A comply with applicable health and safety requirementsas part of the selection proces

31、s?c. 贵公司分包商是否具有书面安全健康制度?Do your subcontractors have a written Safety & Health是Yes 否No 不适用N/A Program?d. 贵公司是否让分包商参加下列活动：Do you include your subcontractors in:安全健康岗前培训Safety & Health Orientation 是Yes 否No 不适用N/A 安全健康会议Safety & Health Meeting是Yes 否No 不适用N/A 检查Inspections是Yes 否No 不适用N/A 评审Au

32、dits是Yes 否No 不适用N/A YNN/A11.检查和审计 Inspections and Auditsa.贵公司是否进行安全健康检查？Do you conduct safety and health inspections?是Yes 否No b.贵公司是否进行安全健康制度评审？Do you conduct safety and health program audits?是Yes 否No c. 是否提供过去3年现场检查记录样本（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. 是否提供过去3年检查发现问题的制定行动项Action plan of corrections in past 3 years?是Yes 否No e. 是否有整改记录？Are corrections of deficiencies documented?是Yes 否No f. 是否提供过去3年现场安全审计样本（至少2份）？Could they provide at least 2 safety audit report ?是Yes 否No g. 是否提供过去3年现场安全审计纠正措施？是Yes 否No 安全健康培训SAFETY & HEALTH TRAININ

34、GYNN/A12.安全培训 Safety Traininga.贵公司是否了解法规要求的安全培训？Do you know the regulatory safety training是Yes 否No b. 贵公司员工是否接受过必需的安全培训并有记录？Have your employees received the required safety and requirements training for your employees?是Yes 否No c. 贵公司培训内容是否适用于相关岗位员工？Does the training material suit for employees?是Yes

35、否No d. 贵公司安全培训人员具备相应资质Is the trainer with certain qualificaiton?是Yes 否No 贵公司是否具有针对主管的相关安全健康培训制度？Do you have a specific safety and health training program是Yes 否No for supervisors?e. 是否所有员工接受了相关作业制度培训并能安全地执行工作？Are all employees trained in the work practices needed 是Yes 否No to safely perform his/her jo

36、b?g.是否已将已知的潜在火灾、爆炸或释放毒性危险品的情况和应急行动计划的程序和适用措施告知与该工作相关的每位员工？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?以下填写能负责保证本文件准确性的公司高管人员的姓名和职务：Fill in below Nam

37、e & Title of Company Officer responsible for assuring the accuracy of this document:职务Title 质安科科长 姓名Name xx 日期Date 2015-02-03 信息提交INFORMATION SUBMITTAL所有承包商都需要详尽填写资格预审调查表（PQQ）。在主承包商之下工作的一次性服务承包商或分包商必须提供至少一份PQQ表供审查。但是，希望进入现场核准承包商名单（核准三年）的承包商还必须提供下列检查项：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: 劳工赔偿文件（来自贵公司的保险人）Workers Compensation documentation (from your insurance carrier)保险证书Insurance Certificate(s)伤病指数和文件（过去三年）Injury/Illness Index and documentation (Past 3 Years)安全健康制度Safety & Health Program危险品危害通报程序Hazard Communication Program 呼吸防护制度Respiratory Prot

40、ection Program 事故意外调查程序Accident/Incident Investigation Procedure 不安全条件报告程序Unsafe Condition Reporting Procedure 安全健康检查评审程序和表格Safety & Health Inspection / Audit Procedure & Form 岗前安全健康培训（大纲）Safety & Health Orientation (Outline) 安全健康培训制度（大纲）及培训记录示例Safety & Health Training Program (Outli

41、ne) with examples of training records 组织机构图Organization Chart贵公司为在该设施中可用于作业的主要设备清单（如起重机、JLG、叉车等）List of major equipment (e.g., cranes, man-lifts, forklifts, etc) your company has available for work at this facility. * 在承包商核准程序期间，xx可能要求审查其它相关信息，例如记录和符合性证据。SHGOC may request a review of other pertinent

42、 information such as records and evidence of compliance during the Contractor approval process.PQQ评估- 仅供xx粮油使用 - PQQ EVALUATION- SHGOC USE ONLY -不需填写 仅供业主使用DO NOT FILL OUT - OWNER USE ONLY承包商为：Contractor is:A级 获准（得分90 100），该承包商将被列入xx优选承包商名单。A Approved (score 90 100), the contractor will be on the pr

43、eferred SHGOC Contractor list.B级 获准（得分80 89.99），该承包商将得到xx评估结果并被要求解决安全制度问题。该承包商将被列入xx优选承包商名单。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级 可能获

44、准（得分70 79.99），要求现场主管核准*特定工作。承包商将得到xx评估结果。除非问题得到解决并符合本SWP的要求，否则该承包商将不被列入xx优选承包商名单。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 级 可能要制订书面