OSHA Safety Questionnaire

OSHA Safety Questionnaire and Safety Services Agreement

Client Name:    Service Provider Name:

Effective Date:

WHEREAS

WHEREAS, Client operates facilities and engages in activities subject to occupational safety and health standards and requires a formal assessment of workplace hazards and compliance practices; and

WHEREAS, Service Provider represents that it has the requisite qualifications to conduct safety evaluations, provide recommendations to achieve compliance with applicable occupational safety standards, and deliver related safety services pursuant to the Scope of Work set forth herein; and

WHEREAS, the parties desire to document the Client's current safety practices, identify deficiencies and corrective actions, and memorialize the terms under which the Service Provider will perform the services described below.

SAFETY QUESTIONNAIRE — GENERAL INFORMATION

Facility Address:

WORKPLACE SAFETY ASSESSMENT QUESTIONS

1. Has a formal hazard assessment been conducted for the facility within the last 12 months?    Yes    No

2. Are employees provided appropriate personal protective equipment (PPE) and training for its use?    Yes    No

3. Are written emergency action plans and evacuation procedures maintained and posted?    Yes    No

4. Is a written Hazard Communication (HazCom) program in place, including Safety Data Sheets (SDS) access?    Yes    No

5. Has the facility recorded any work-related fatalities, lost-time injuries, or OSHA recordable incidents in the last 36 months?    Yes    No

6. Are written programs in place for Lockout/Tagout, Confined Space Entry, Fall Protection, Respiratory Protection, and Machine Guarding where applicable?

SCOPE OF WORK

PAYMENT TERMS

Total Fee (USD):

Late Fee: % per month on overdue balances

TERM AND TERMINATION

Term Commencement Date:    Term End Date (if any):

Either party may terminate this Agreement for cause if the other party materially breaches any obligation and fails to cure such breach within the notice period specified above. Termination shall not relieve either party of obligations accrued prior to termination.

CONFIDENTIALITY

The parties acknowledge that Service Provider may receive access to Client's nonpublic safety records, incident investigations, personnel medical information, and other proprietary information (Confidential Information). Service Provider agrees to hold Confidential Information in strict confidence, to use it solely for performance of the Scope of Work, and not to disclose it to third parties except as required by law or with Client's prior written consent. Confidentiality obligations survive termination for a period of three (3) years.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to that State's conflicts of law rules.

ENTIRE AGREEMENT

This document, including the Questionnaire, Scope of Work and Payment Terms, constitutes the entire agreement between the parties relating to the subject matter hereof and supersedes all prior proposals, representations, and understandings, whether written or oral. Any modifications must be made in writing and signed by authorized representatives of both parties.

CERTIFICATIONS AND REPRESENTATIONS

The undersigned certify that the information provided herein is true and correct to the best of their knowledge, that they are authorized to execute this Agreement on behalf of the named party, and that the Service Provider will perform services in a manner consistent with applicable occupational safety requirements and recognized industry standards.

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