ࡱ > s bjbj]] 7ij7ij ^ ^ W W 8 U ( c ~ " " r $ l $ 8 HU JU JU JU JU JU JU X [ V JU $ i" i" @ $ $ JU W W f _U K' K' K' $ R W W 8 HU K' $ HU K' K' K D bO 0Oub % R L & 4U uU 0 U L f [ c% [ L bO bO & [ O $ $ K' $ $ $ $ $ JU JU -& $ $ $ U $ $ $ $ [ $ $ $ $ $ $ $ $ $ ^ : Environment Safety & Health Contractor Questionnaire
Company Name:Company Address:Company POC Name:Company POC Email:Company POC Phone:NAICS Code:Number of Employees (Company-Wide):Work Site Location: FORMCHECKBOX Fort Worth FORMCHECKBOX Marietta FORMCHECKBOX Palmdale FORMCHECKBOX OtherDescription of work to be performed:
Contractor Orientations: Review all applicable orientation topics with employees/subcontractors.
FORMCHECKBOX Contractor ESH Handbook FORMCHECKBOX Site Contractor Orientation/Safety Briefing
Supply Chain Website HYPERLINK "/en-us/suppliers/business-area-procurement/aeronautics/terms-and-conditions/environment-safety-health.html"/en-us/suppliers/business-area-procurement/aeronautics/terms-and-
conditions/environment-safety-health.html
Environmental, Safety & Health Tasks: Check all tasks that may apply to work performed on LM Aeronautics sites.
FORMCHECKBOX Abrasive Blasting FORMCHECKBOX Asbestos or Lead Abatement FORMCHECKBOX Chemical Use FORMCHECKBOX Cleanroom Activities
FORMCHECKBOX Compressed Gas Use FORMCHECKBOX Confined Space Entry FORMCHECKBOX Construction/Demolition FORMCHECKBOX Crane/Hoist/Rigging
FORMCHECKBOX Cryogenic Liquid Use FORMCHECKBOX Discharge to Drains/Sewers FORMCHECKBOX Earth Moving and Paving FORMCHECKBOX Electrical Work
FORMCHECKBOX Elevator Work FORMCHECKBOX Excavation/Trenching/Shoring FORMCHECKBOX Explosives or Pyrotechnics Use FORMCHECKBOX Fueling Operations
FORMCHECKBOX HazMat Transportation FORMCHECKBOX HazWaste Disposal FORMCHECKBOX HVAC Work FORMCHECKBOX Heavy Equipment Use
FORMCHECKBOX Hot Work Activities FORMCHECKBOX Install/Maintain Radiation Devices FORMCHECKBOX Install/Maintain RF Devices FORMCHECKBOX Install/Test Fire Equipment FORMCHECKBOX Janitorial Activities FORMCHECKBOX Landscape or Snow Removal FORMCHECKBOX Maintenance w/o Safeguards FORMCHECKBOX Marine/Shoring Operations FORMCHECKBOX Nanomaterial Use FORMCHECKBOX Onsite Food Preparation FORMCHECKBOX Painting Activities FORMCHECKBOX Plumbing Activities
FORMCHECKBOX Power Tool Use FORMCHECKBOX PIV Use FORMCHECKBOX Remediation Activities FORMCHECKBOX Roofing Operations
FORMCHECKBOX Scaffolding Operations FORMCHECKBOX SCBA Activities FORMCHECKBOX Spill Response Activities FORMCHECKBOX Steel Erection
FORMCHECKBOX Telecommunications Work FORMCHECKBOX Troubleshoot w/o Safeguards FORMCHECKBOX Use of Lockout/Tagout Procedures FORMCHECKBOX Waste/Recycling Activities FORMCHECKBOX Work Requiring Fall Protection FORMCHECKBOX Work Requiring Air Permits FORMCHECKBOX Other__________________________________
Citation, Notice of Violation, Fatality history
Did the company receive any Citations or Notice of Violations within the past 3 years? Yes FORMCHECKBOX No FORMCHECKBOX
(OSHA, Cal/OSHA, EPA, CalEPA, etc.)
Did the company experience any occupational fatalities within the past 3 years? Yes FORMCHECKBOX No FORMCHECKBOX
Contractors performing work in California
Employers with 10 or more employees: Injury and Illness Prevention Program (IIPP) in place Yes FORMCHECKBOX No FORMCHECKBOX
Employers with less than 10 employees: Oral communication of safety concerns w/sign-in sheet Yes FORMCHECKBOX No FORMCHECKBOX
Asbestos Notification received and reviewed with employees Yes FORMCHECKBOX No FORMCHECKBOX
Contractor is responsible for insuring flow-down of this information to all levels of employees (including subcontractors). Contractor shall provide a copy of this form to the LM POC, ESH, and maintain a copy on file to provide upon request.
Contractor POC NameSignatureDate
LM Aero ESH NameSignatureDate
51 Martin Aeronautics Company
PAGE
Important Notice: The current version of this form can be found on the LM Intranet.
Page PAGE \* Arabic 1 51 Martin Aeronautics Company 12109-08122025
Important Notice: A hard copy of this blank form may not be the version currently in effect.
Page The current version of this form is the version in the LM Intranet. 12109-07222008
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