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MEDIA INQUIRIES
Project Funding and Engagement Director Chelsea Murphy joins ECT
October 25, 2024
Read More »
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ECT Subcontractor H&S Prequalification - Renewal Application
Section 1: Subcontractor Information
Company Legal Name:
Company legal name as it appears on the W-9:
Primary Mailing Address:
Street Address:
Address Line 2:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Website:
H&S Manager Information:
H&S Manager Name and Title (if you don't have one, please write "Not Applicable"):
H&S Manager Phone:
H&S Manager Email:
Current Date:
Date:
Recent Service:
Primary ECT contact(s) and office(s) most recently serviced:
NAICS Code(s):
Please list relevant NAICS Code(s):
Business Certifications:
If you possess any of the following Business Certifications, please check all that apply:
Small Business
Non-profit Organization
Businesses owned by economically disadvantaged individuals (DBE)
Woman Owned
Disability Owned
Veteran Owned
Service‐Disabled Vet owned
Black American owned
Hispanic American owned
Native American owned
Asian‐Pacific American owned
Subcontinent Asian American owned
HUBZone Certified
Other - Explain
Not applicable
If you selected "other," please specify below:
Please characterize the work you provided for ECT over the past 12 months.
Section 2: Document Uploads
Please provide your most current copy of the following items.
You may upload up to a total of 10 MB for all of your files; if you need to upload more or are experiencing difficulty uploading, please let us know and we will contact you directly. You may include up to 3 files per upload button. Hold down the command key to select multiple files from the same folder.
OSHA 2023 300/300A logs:
2024 EMR verification on insurance company letterhead:
Sample of completed Job Safety Analysis (similar for work to be performed with ECT):
Certificate of Insurance (COI) – Scroll to the bottom of the page to view our COI requirements
Business Certifications – If you answered yes to one or more of the Business Certifications in Section 1, please provide documentation:
Context and Explanation – Should any of the requested information not be available or need explanation, please provide an explanation here:
Next Steps
Once your renewal application is received, the information will be reviewed and you will be contacted either to confirm approval and active status in our system or to request additional or supplementary information such as HAZWOPER training certifications, procedural documentation, or other related information. To complete the application process, please complete the required signatures below.
"By signing below, I acknowledge the information provided is current and true and I have provided the support information requested or provided explanations why the information was not provided. Additionally, the submitting subcontractor agrees to follow ECT health & safety requirements and applicable state or Federal health & safety regulations."
Signature
Name
Title
Date
Submit
KP Test Form
Name:
Company:
Phone:
Email:
Please briefly explain your inquiry:
File Upload Section
You may upload up to a total of 10 MB for all of your files; if you need to upload more, please let us know and we will contact you directly.
You may include up to 3 files per upload button. Hold down the command key to select multiple files from the same folder.
File Upload 1:
File Upload 2:
File Upload 3:
File Upload 4:
File Upload 5:
File Upload 6:
File Upload 7:
File Upload 8:
Submit
ECT Inquiry
Name:
Company:
Phone:
Email:
Please briefly explain your inquiry:
Submit
ECT Subcontractor H&S Prequalification - New Application
Section 1: Subcontractor Information
Company Legal Name:
Company legal name as it appears on the W-9:
Primary Mailing Address:
Street Address:
Address Line 2:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Website:
H&S Manager Information:
H&S Manager Name and Title (if you don't have one, please write "Not Applicable"):
H&S Manager Phone:
H&S Manager Email:
Current Date:
Date:
Recent Service:
Primary ECT contact(s) and office(s) most recently serviced:
NAICS Code(s):
Please list relevant NAICS Code(s):
Business Certifications:
If you possess any of the following Business Certifications, please check all that apply:
Small Business
Non-profit Organization
Businesses owned by economically disadvantaged individuals (DBE)
Woman Owned
Disability Owned
Veteran Owned
Service‐Disabled Vet owned
Black American owned
Hispanic American owned
Native American owned
Asian‐Pacific American owned
Subcontinent Asian American owned
HUBZone Certified
Other - Explain
Not applicable
If you selected "other," please specify below:
Section 2: Subcontractor Health & Safety Information
Please provide the following data for the last three years below. If not applicable, please mark "NA" in the fields.
TRIR
– Total Recordable Incident Rate:
TRIR 2023
TRIR 2022
TRIR 2021
DART
– Days Away, Restricted, or Transferred:
DART 2023
DART 2022
DART 2021
EMR
– Experience Modification Rate:
EMR 2024
EMR 2023
EMR 2022
Citations/Safety
Has your company received a citation from OSHA or state equivalent, or other agency regarding an injury or environmental incident within the past 5 years?
Yes
No
If yes, please provide a brief summary:
Has your company experienced a work-related, OSHA defined severe injury including hospitalization, amputation, or death in the past 5 years?
Yes
No
If yes, please provide a brief summary:
H&S Program Information
Do you have H&S program information available about your company?
Yes
No
Not applicable
If you said yes, please check all that apply for your company.
We have a written H&S Program.
We hold Tailgate/Job Site Safety Meetings.
We have an Injury Management & Reporting Procedure.
We have a written Hazard Communication (HazComm) policy/program.
We have written H&S procedures for the work we may perform for ECT.
We prepare job-specific health & safety plans and job safety and hazard assessments.
We have a “Stop Work Authority” policy.
Section 3: Document Uploads
Please upload the following supporting documents.
You may upload up to a total of 10 MB for all of your files; if you need to upload more or are experiencing difficulty uploading, please let us know and we will contact you directly. You may include up to 3 files per upload button. Hold down the command key to select multiple files from the same folder.
H&S Program Table of Contents:
OSHA 300 and 300A logs for 2023, 2022, and 2021:
Explanation of any severe injuries, hospitalizations, deaths or citations in last 5 years:
On Insurance carrier letterhead, EMR verification for years 2024, 2023, and 2022:
Sample of completed Job Safety Analysis (similar for work to be performed with ECT):
Certificate of Insurance (COI) – Scroll to the bottom of the page to view our COI requirements
Current W-9 form (Signed) – A link to a fillable W-9 form is provided below.
Business Certifications – If you answered yes to one or more of the Business Certifications in Section 1, please provide documentation:
Context and Explanation – Should any of the requested information not be available or need explanation, please provide an explanation here:
Next Steps
Once your application is received, the information will be reviewed and you will be contacted either to confirm approval and active status in our system or to request additional or supplementary information such as HAZWOPER training certifications, procedural documentation, or other related information. To complete the application process, please complete the required signatures below.
"By signing below, I acknowledge the information provided is current and true and I have provided the support information requested or provided explanations why the information was not provided. Additionally, the submitting subcontractor agrees to follow ECT health & safety requirements and applicable state or federal health & safety regulations."
Signature
Name
Title
Date
Submit
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