ENVIRONMENTAL, HEALTH AND SAFETY Refs: Code of Federal

Regulations (CFR); Occupational

(EHS) Safety and Health Administration
REQUIREMENTS FOR PURCHASE ORDERS (OSHA), Environmental
AND SUBCONTRACTS Protection Agency (EPA),
Federal, State and Local EHS
SA-019 (09/13) Regulations and Standards.

It is the policy of Raytheon Company that the establishment of safe, healthy working conditions and
safe work practices are essential requirements at all locations, including customer locations.
For ease of reference, all awarded or potential contractors, subcontractors, suppliers and vendors that
receive this document shall be referred to as the “Contractor”. That term includes persons or firms
performing work for the Contractor in connection with a purchase order or subcontract Raytheon
Company issued to the Contractor.
These requirements apply to all requests for proposal (RFPs), requests for quotation (RFQs),
subcontracts, purchase orders, service agreements or other instruments issued (hereinafter
collectively referred to as the “Purchase Order”) for activities when all or part of required performance
will be accomplished on Raytheon Company property or whenever the premises are under the control
of Raytheon Company. These SA-019 requirements apply in addition to and not in place of other
requirements set out in the Purchase Order.

Section A: General Requirements

1. Contractor must conduct its activities so that equipment, supplies and work practices are safe for
workers and can be understood by all workers and others present at the work location.
2. Contractor shall provide a safe work area free from recognized hazards, shall use due care to
prevent damage to property materials and equipment, and shall comply with all applicable federal,
state, and local environmental, health and safety (EHS) laws, regulations and standards.
Contractor shall restore to original condition any damaged property, materials and equipment.
3. All items furnished and all work performed by Contractor shall comply with the most current
applicable requirements of the U.S. Occupational Safety and Health Administration (OSHA), U.S.
Environmental Protection Agency (EPA), federal, state and local EHS regulations and standards in
the jurisdiction where the work is being performed. Any failure to comply with the applicable laws,
regulations, and standards may be grounds for termination of the Purchase Order.

Section B: Pre-Bid Requirements

1. Contractor shall provide pre-qualification information using the Raytheon Company Contractor
Pre-Qualification Safety Record and Information Form (Attachment EHS001), upon
submission of bid or before pre-bid walk-through of job site (or pre-bid meeting) if applicable.
Contractor shall update the Attachment EHS001 annually by February 1 for the duration of the
Purchase Order.
2. Contractor shall appoint a qualified safety representative to act as a focal point for all matters
relating to EHS performance.
3. Contractor shall provide no later than submission of its bid a Contractor’s Safe Work
Certification Form (Attachment EHS002).
4. Contractor shall conduct a hazard assessment during the “job walk-through” (or similar pre-bid site
review) describing the scope of work, identifying the hazards associated with the work, and
identifying measures to be taken to protect Raytheon Company’s employees, Contractor’s
employees and any other people present on the job site from identified hazards in accordance
with all applicable federal, state and local laws, regulations, and ordinances. Protective measures

1 of 3
 shall include, but shall not be limited to, engineering controls, safe work practices, training, and
personal protective equipment. If a “job walk-through” (or similar pre-bid site review) is deemed
unnecessary by Raytheon Company, or otherwise not conducted, Raytheon Company will
establish a reasonable timetable for the receipt of a completed Contractor Safety Checklist from
Contractor.
5. Before performing any work at a site located in California, Contractor shall provide a copy of its
Injury and Illness Prevention Program/Plan.

Section C: Post Award Requirements

1. Contractor shall provide Raytheon Company a Contractor Safety Checklist: Potentially
Hazardous Work Requirements & Identification Form (Attachment EHS003) before the
commencement of work. NOTE: This form is solely for purposes of information gathering by
Raytheon Company about a Contractor’s EHS program, procedures, and past training history.
Contractor shall remain responsible for the safety of its employees, as well as be responsible for
any harm or damage resulting from any safety hazards or environmental contamination the
Contractor introduces onto any Raytheon Company property or premises under the control of
Raytheon Company.
2. After Purchase Order award and prior to commencement of work, Contractor shall submit to
Raytheon Company a completed Contractor Summary Data For Safety Program Form
(Attachment EHS004), Sections II through VI, including a written and dated site-specific Safety
and Health Plan establishing safety and health policies, programs, and procedures governing
work.
3. Contractor shall conduct all work in accordance with the approved Safety and Health Plan. The
Raytheon Company approved Safety and Health Plan shall be available on-site at all times during
work operations.
4. Contractor shall designate in writing an on-site safety representative who will be Contractor’s main
point of contact with Raytheon Company.
5. Contractor shall provide a telephone or other reliable means of communication at the work site.
6. Contractor shall post the telephone number and access route descriptions for emergency contacts
with fire department, hospitals, emergency medical services and police agencies serving the work
site.
7. Contractor shall assess the work area for environmental, safety, and health hazards (or potential
hazards) and mitigate all potentially unsafe situations, conditions, and activities.
8. Contractor shall maintain ready availability at the work site of all required hazardous material lists,
Safety Data Sheets (SDS), OSHA information posters, safe practices codes, insurance certificates
and other such notices as required by federal, state or local laws.
9. Contractor shall provide and maintain adequate, readily-available first-aid supplies, sanitation
facilities, drinking water, fire extinguishers, and personal protective equipment.
10. Contractor shall provide and maintain adequate and current safety training for the site safety
requirements as identified in the Safety and Health Plan for all contract and lower-tier subcontract
suppliers assigned to perform work under the contract. (As used herein, “current” means up to
date training that meets regulatory requirements.) Performance and documentation of safety
inspections to adequately manage risk shall occur at least weekly or as required by the local
Raytheon representative.

SA-019 (09/13) 2 of 3
11. Contractor shall plan, perform, and document safety meetings at least weekly and whenever new
safety-impacting work phases are to commence.
12. Contractor shall have provisions for ensuring 100% fall protection whenever Contractor’s
personnel or its lower-tier subcontractors and suppliers are engaged in activities at elevated
working surfaces 4 feet or more above ground or a lower level.
13. Contractor shall have written guidelines and management practices for enforcement of all safety &
health requirements.
14. Contractor shall coordinate and control safety activities of its lower-tier subcontractors and
suppliers in accordance with the Contractor Summary Data For Safety Program Form
(Attachment EHS004).
15. Contractor shall immediately report, or as soon as practicable, any and all accidents on the job
site involving Contractor’s employees or its subcontractor’s personnel to Raytheon EHS and the
Raytheon project manager. Immediately or as soon as practicable, Contractor shall initiate an
incident investigation to identify root cause, corrective/preventive action, and implement corrective
actions as soon as possible to ensure the incident does not occur again. A written report must be
prepared by Contractor and submitted to Raytheon EHS and the Raytheon project manager within
48 hours of each incident.
16. Contractor shall timely submit all various EHS reports as required. These reports may include, but
are not limited to, Accident/Damage reports, Contractor Safety Violation reports, and/or Incident
Investigation reports.

Section D: Site Specific Requirements and Attachments

1. Contact Raytheon Company if this SA-019 is delivered and one of the following blocks is not
marked with an “X”:

There are no additional site-specific EHS Requirements

Site-specific EHS Requirements are described in an attached Addendum

2. The following Raytheon Company forms are attached and incorporated by this reference.
EHS001. Raytheon Company Contractor Pre-Qualification Safety Record and Information Form
EHS002. Contractor’s Safe Work Certification Form
EHS003. Contractor Safety Checklist: Potentially Hazardous Work Requirements &
Identification Form
EHS004. Contractor Summary Data and Safety Program Form

SA-019 (09/13) 3 of 3
 RAYTHEON COMPANY CONTRACTOR PRE-QUALIFICATION SAFETY RECORD AND
INFORMATION FORM
ATTACHMENT EHS001 (PRE-BID)

Environmental, Health and Safety (EHS) Record and Information

Company Name:

Address:

Point of Contact:

Phone / Fax:

Signature:

Date:

This form must be executed by Contractor’s Officer (or similar company representative
with authority to bind the company)

1. Has your company received any environmental or safety citations from any U.S.
Government, city, or local entity for the past ten years? Yes No. If yes, please
attach copies to this form.

2a. List your firm’s Experience Modification Rate (EMR) for the past three consecutive years.

- EMR: -EMR: -EMR:

2b. The Contractor/bidder shall obtain and provide as a part of the bid a signed and dated letter
from the appropriate Workers’ Compensation carrier stating that the EMR listed for the
three (3) years in Item 2a above is correct. Failure of bidder to provide a signed and dated
letter from the Workers’ Compensation Carrier may disqualify bidder from competing in the
bidding process. Those Contractors who are self-insured must attach a letter signed by an
officer of their company stating that they are self-insured and do not have an EMR.

3a. How often are accident reports (OSHA 300) and report summaries sent to the following?

Never Monthly Quarterly Annually

President of Firm
Safety Director
Other
Other

ATTACHMENT EHS001 (PRE-BID) (09/13) 1 of 6

 b. Please explain the reporting structure for the individuals listed above (e.g., How many
direct reports does the “Safety Director” have? What is the title and/or position of the
individual who the “Safety Director” reports to?).

4a. Please use your current (year to date) and last three (consecutive) years of OSHA No. 300
Log data to fill in the following:

NAICS Code: Insert Year:

A) Total number of OSHA recordable cases:

B) Number of transfer and restricted cases:

C) Number of lost workday cases:

D) Number of lost workdays:

E) Number of fatalities:

F) Employee hours worked each year:

4b. Complete the following rate information based upon current year-to-date numbers taken
from your firm’s OSHA No. 300 log, as well as for your last three consecutive years. (Refer
to item No. 4(a) above for calculation purposes)

Insert Year:
A) OSHA Recordable Incident Rate:
B) DART Rate:
C) Lost Workday Rate:

Rate Calculation Formula:

Number of Cases X 200,000 = Rate

Total Hours Worked Per Year

Example: 5 OSHA Recordable Cases X 200,000 = 1,000,000 = 6.9

Total Hours Worked 144,000 144,000

5. Does your firm have a written Company Safety Policy (or similar purpose document) signed
by a company officer? Yes No

6. Does your firm have an established Safety Program (IIPP for California Contractors)?
Yes No

7. Does your firm have a written Hazard Communication Program? Yes No

ATTACHMENT EHS001 (PRE-BID) (09/13) 2 of 6

Explain any
“No”
responses to
questions 5-7
(attach
additional
pages if
needed)

ATTACHMENT EHS001 (PRE-BID) (09/13) 3 of 6

8. Identify by name and title the person within your firm directly responsible for the firm’s Safety
Program Management:

Name Phone

9. How often do you hold site “toolbox” safety (or similar purpose) meetings for field teams?
Daily Weekly Monthly After every injury or near miss Only on an “as
needed” basis

(Please explain)

Yes No
10. Do you have a safety orientation program for new hires?
If yes, does it include instruction on the following?
a. Your company’s safety policy, rules, and procedures
b. Head Protection
c. Eye Protection
d. Hearing Protection
e. Respiratory Protection
f. Fall Protection (Competent Person Training Required)
g. Scaffolding/Work Platform (Competent Person Training Required)
h. Perimeter Guarding/Floor, Wall and Roof Openings
i. Housekeeping
j. Fire Protection
k. First-Aid Facilities
l. Emergency procedures - Rescue/Evacuation
m. Toxic Substances
n. Trenching and Excavation (Competent Person Training Required)
o. Signs, Barricades, Flagging
p. Electrical Safety, Lockout/Tagout Procedures
q. Rigging and Crane Safety (Competent Person Training Required)
r. Hazard Recognition
s. Confined Space Entry (Competent Person Training Required)
t. Hazard Communication (and Safety Data Sheets)

ATTACHMENT EHS001 (PRE-BID) (09/13) 4 of 6

 Yes No
11. Do you have a safety orientation program for newly hired or promoted supervisors?
If yes, does it include instruction on the following?
a. Safe Work Practice
b. Methods of Safety Supervision
c. Toolbox Safety Meeting (or similar purpose meeting)
d. Emergency Procedures
e. First-Aid Facilities
f. Accident Investigation
g. Fire Protection and Prevention
h. New Worker Orientation
12. Does your company have a Substance Abuse Program? Yes No
If yes, how long has this program been in place? years

13. Do you require and verify that your employees and any lower tier contractors that you hire
conduct and document hazard assessments for high risk jobs/tasks to ensure hazards, risks
and mitigation measures are identified before the commencement of work? Yes No
14. Describe how you will communicate and enforce regulatory and Raytheon safety
requirements applicable to your employees and lower tier contractors that you bring on site
to support the project.

15. What is your process to verify that your employees and lower tier contractors that you hire to
support the project have the required experience, qualifications, training and PPE/equipment
to perform the scope of work safely?

16. What is your process to investigate and implement corrective measures to address safety
issues or serious safety incidents, including those involving lower tier contractors that you
hire for the project?

ATTACHMENT EHS001 (PRE-BID) (09/13) 5 of 6

17. Please use the space below to provide additional relevant information regarding your
company’s environmental, health, and safety programs:

18. Contractor agrees to use the above criteria when selecting lower tier contractors. Contractor
shall maintain records of all such evaluations and make them available for review by
Raytheon Company when requested.

ATTACHMENT EHS001 (PRE-BID) (09/13) 6 of 6

 CONTRACTOR’S SAFE WORK CERTIFICATION FORM
ATTACHMENT EHS002 (PRE-BID)

Contractor’s Safe Work Certification

Contractor certifies that all of its employees and the employees of any/all lower-tier contractors
have successfully completed training in all project-related safety disciplines.
Contractor agrees to observe, at a minimum, all applicable occupational safety and health
regulations promulgated by local, State, and/or Federal agencies; and Contractor shall,
preserve the safety of employees and the general public while working on contracted work sites.
Contractor hereby agrees, holds harmless and indemnifies Raytheon Company, its officers,
employees, and agents from and against any and all damages, losses, liabilities, penalties,
claims, demands, suits or costs arising from or related to Contractor’s failure to comply with
local, State, and/or Federal occupational safety and health regulations.

Name of Contractor:

Authorized Signature: Date:

Name:

Title:

Contractor Address:

Name(s) of Supervisor(s):

Please return this form and all required documents to the Purchasing Representative at
Raytheon Company.

This Section Completed by Raytheon Company:

RAYTHEON COMPANY Date:

Company - EHS Agent:

ATTACHMENT EHS002 (PRE-BID) (09/13) 1 of 1

 CONTRACTOR SAFETY CHECKLIST: POTENTIALLY HAZARDOUS WORK REQUIREMENTS &
IDENTIFICATION FORM
ATTACHMENT EHS003 – (POST AWARD)

Contractor Safety Checklist:

Potentially Hazardous Work Requirements & Identification

The Contractor is required to identify the types of hazardous (or potentially hazardous) work that may be
conducted by the Contractor as part of the applicable purchase order and/or subcontract by completing
the checklist below.
The Contractor is to review all work scenarios and check (“”) for all that apply or may apply.
Additionally, the Contractor shall insert a “yes,” “no,” or “not applicable (N/A)” for each Special
Program/Program Elements checked, as well as insert its Contractor initials as applicable. If the
“Possible Work Scenario” is not listed in Nos. 1 -17, below, the Contractor shall separately identify its
particular Work Scenario and applicable safety concerns and actions under No. 18 in the attached
checklist. In addition, site-specific or unique requirements not otherwise addressed in the checklist are
set forth under No. 19. Note: Any reference to an environmental, health and/or safety law, regulation,
standard, policy and/or procedure shall be assumed to be a reference to the most current, applicable
version in effect as of the date of completion of this form. Contractor shall provide Raytheon Company a
copy of this checklist after completion and also keep a copy on file for on-site review by Raytheon-EHS
or any public agency.

Name of Contractor:

Date Submitted:

Project Location:

The Contractor shall also provide the following information as part of this Contractor Safety Checklist
form:
Please address and highlight how your site specific Safety and Health Plan (or EHS plan) addresses any
unique aspects of this Raytheon Company project such as on-airport work, potential hazardous material,
confined spaces, fall protection, excavations, etc. Your discussion should also provide your assessment
of the Project work area for environmental, safety, and health hazards (or potential hazards) and
correction of all unsafe situations, conditions, and activities (attach additional pages as necessary):

ATTACHMENT EHS003 – (POST AWARD) (09/13) 1 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, initial when
Special Program/Program Elements
but are not limited Applicable No or fully
to: N/A addressed
1. Work requiring (a) Has Hazard Communication
the use of standard been addressed?
Chemical
(b) Is Special Training for unusual
substances
materials required?
(Paints, coatings,
adhesives, (c) Has review of Safety Data
solvents, gases, Sheets (SDSs) with Raytheon-
powders, or etc.) EHS been completed?
(d) Are copies of training records for
Contractor employees available
for review upon request by
Raytheon-EHS?
(e) Are all chemical containers
labeled as required by the
OSHA Hazard Communications
Std. and DOT Regulations?
(f) Personal Protective Equipment
including but not limited to
respiratory protection, gloves,
goggles, coveralls, aprons, face
splash shields, etc. have
been/will be provided to
employees?
(g) Does Contractor understand the
procedures/practices for
disposal of all hazardous waste
generated by work operations?
2. Work requiring (a) Have Excavation/Trenching
excavation/ Safety standards been
trenching addressed?
(b) Have procedures/practices to
ensure that a “Competent
Person” as defined by OSHA
remains on-site during the entire
period trenching work/entry is
occurring?
(c) Does excavation/trenching
practice include shoring, sheet
piling, or bracing as required by
the applicable Federal, State
and local laws and regulations?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 2 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, initial when
Special Program/Program Elements
but are not limited Applicable No or fully
to: N/A addressed
2. Work requiring (d) Has verification of the location of
excavation/ underground services including,
trenching but not limited to gas, water,
(continued from electrical, chemical piping,
preceding page) telephone, sewers, alarms and
fire protection systems been
completed prior to excavation?
(e) Has Contractor erected a
protection barrier at the edge of
any trench and/or instituted
procedures/practices to ensure
that tools, stones and dirt are
kept away from the edge of any
trench?
3. Work involving (a) The most stringent Burning/
cutting, burning, Welding/Cutting Safety
welding, or Standards / Practices have been
brazing, etc. reviewed and complied with?
(b) Fire Watch as required by OSHA
and/or State or Local EHS
requirements (applying the more
stringent standard)?
(c) Shields, non-combustible tarps
will be provided by Contractor to
prevent potential fire exposure
to combustible materials?
(d) Hot Work Permit has been
requested from Raytheon-EHS
(or evidence provided that
Contractor has obtained the
necessary Hot Work permit)?
(e) Personal Protective Equipment
including but not limited to
respiratory protection, leather
gloves, leather forearm covers
goggles, coveralls, welders
mask, etc. have been provided
to the employees?
4. Work involving (a) The most current and stringent
elevated heights Fall Protection Regulations have
been reviewed?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 3 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, No or initial when
Special Program/Program Elements
but are not limited Applicable N/A fully
to: addressed
4. Work involving (b) Fall protection equipment
elevated heights is/will be in place as required
(continued from by applicable laws?
preceding page) (c) Training for Fall Protection
Equipment and Rescue
Operations current and
complete?
(d) Upon request by Raytheon-
EHS, Contractor shall provide
copies of training records for
employees and ensure that
they are available for review.
(e) Personal Protective Equipment
including, but not limited to
lanyards, safety lines,
harnesses, have been/will be
provided by Contractor?
5. Work involving (a) Does Contractor address
Scaffolding, Lift or Scaffolding Safety and provide
Ladders an onsite “Competent Person”
to inspect the safety of the
scaffolding on a daily basis (or,
at a minimum, comply with the
most stringent EHS
requirement applicable)?
(b) Handrails, midrails, and
toeboards will be provided for
any scaffolding four or more
feet above ground or lower
level (or, at a minimum,
compliant with the most
stringent EHS requirement
applicable)?
(c) For scaffolds over two lifts
high, tie-off will be in place (or,
at a minimum, compliant with
the most stringent EHS
requirement applicable)?
(d) Scaffolding includes ladders in
place for access and workers
will be prohibited from climbing
on bracing?
(e) Pinning for all connections
(including wheeled casters) in
place?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 4 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, No or initial when
Special Program/Program Elements
but are not limited Applicable N/A fully
to: addressed
5. Work involving (f) All wheels will be locked
Scaffolding, Lift or before use of scaffolding
Ladders equipment (or, at a minimum,
(continued from compliant with the most
preceding page) stringent EHS requirement
applicable)?
(g) Scaffolds shall never be
moved with people on them?
(h) Appropriate buffer zones shall
be established and place
guards or barriers as warnings
will be provided?
(i) Contractor will inspect and
document daily inspections?
(j) Contractors shall provide their
own lifts and ladders of the
appropriate type and length for
the work to be performed?
(k) Any stepladders required will
be fully open and set level?
(l) Ladder inspections will be
performed before each use?
(m) Metal and conductive ladders
will not be used?
(n) Work on ladders will be
performed facing the ladder
with both feet on the rungs
unless a ladder platform is
used?
6. Work involving (a) Upon request by Raytheon-
contact with or EHS, copies of current and up-
disturbance of to-date licenses/registrations
Asbestos or Lead as well as Contractor
containing asbestos/lead removal
materials or practices are available for
potential review?
asbestos/lead
(b) Upon request by Raytheon-
containing
EHS copies all training &
materials
certification records for
employees are available for
review?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 5 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, No initial when
Special Program/Program Elements
but are not limited Applicable or N/A fully
to: addressed
6. Work involving (c) Contractor has obtained
contact with or removal permits and provided
disturbance of appropriate notifications or has
Asbestos or Lead a process in place to address
containing these requirements?
materials or
(d) Contractor ensures that
potential
asbestos awareness training
asbestos/lead
has been conducted?
containing
materials (e) Contractor has
(continued from procedure/practice for the safe
the preceding disposal of Asbestos
page) Containing Material/Lead
Containing Material?
(f) Supplied Air has been certified
as Grade D Breathing Air?
(g) Personal Protective Equipment
including but not limited to
respiratory protection, gloves,
goggles, coveralls, etc. have
been/will be provided by
Contractor?
7. Work involving (a) Contractor ensures drivers of
Powered on-the-road use specialty
Industrial Trucks equipment are licensed and
or specialty documentation is available
powered upon request?
Equipment.
(b) Contractor ensures that only
trained and certified personnel
will operate Powered Industrial
Trucks and documentation is
available upon request?
8. Work requiring (a) Contractor ensures that
Personal hazard assessments have
Protective been performed before issuing
Equipment (PPE) personal protective equipment
to employees?
(b) Contractor ensures that
medical evaluations are
completed prior to the
issuance of respiratory
protection?
(c) Contractor ensures that
employees are trained in the
selection, use, care and
limitations of assigned PPE
equipment?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 6 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, No initial when
Special Program/Program Elements
but are not limited Applicable or N/A fully
to: addressed
9. Work involving (a) Procedures/Practices to obtain
the installation, “Permit to Construct” from
removal and/or Governmental agencies have
modification of been reviewed and
emergency addressed?
generators,
(b) Procedures/Practices to apply
boilers or other
for permits from Governmental
systems that may Agencies have been reviewed
require permits,
and addressed?
including air
(c) Procedures/Practices to
communicate permit limitations
to Raytheon Building/Site
Management have been
reviewed and addressed?
10. Work (a) Entry permits have been/will
involving be reviewed and approved by
“Confined Raytheon-EHS?
Spaces”
(b) Pre-entry/continuous
monitoring for Toxins,
Flammables & Oxygen will be
performed?
(c) A rescue plan & rescue
equipment will be available for
review by Raytheon-EHS prior
to entry into confined space?
(d) NOTE: IF THE LOCAL FIRE
COMPANY (IES) IS/ARE TO
BE USED FOR EMERGENCY
RESCUE, THEN THE
CONTRACTOR SHALL
PROVIDE RAYTHEON
COMPANY A COPY OF THE
AGREEMENT BETWEEN
THE FIRE DEPARTMENT
AND THE CONTRACTOR.
(e) Personal Protective Equipment
including but not limited to
respiratory protection, gloves,
goggles, coveralls, etc. have
been/will be provided by
Contractor?
(f) Upon request by Raytheon-
EHS copies training records
for employees are available for
review?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 7 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, initial when
Special Program/Program Elements
but are not limited Applicable No or fully
to: N/A addressed
10. Work (g) Contractor will ensure
involving ventilation equipment to purge
“Confined confined spaces,
Spaces” telecommunications vaults,
(continued from etc. is available and/or
preceding page) addressed with Raytheon-EHS
prior to entry?
11. Work (a) Contractor certifies that all
involving the use Contractor-provided crane or
of any cranes or hoist equipment is compliant
hoists with Federal, State or Local
safety regulations?
(b) Contractor ensures inspection
& documentation of
inspections for Contractor
provided crane and hoists are
available for review?
(c) Control zones or special work
procedures for overhead work
have been addressed with
Raytheon-EHS, Facilities, and
Security?
12. Work (a) Contractor ensures employees
involving have been trained in
energized Lockout/Tagout Procedures?
equipment
(b) Upon request by Raytheon-
(including work
EHS, documentation of
on Telecom
Employee Training and
Poles)
Contractor Lockout/Tagout
procedure available for
review?
(c) Authorized employees
provided with dedicated locks
and/or tags?
(d) Lockout / Tagout
practice/procedures have been
reviewed?
13. Work (a) Clean up & proper disposal of
involving abrasive residual abrasive blasting
blasting material as hazardous or non-
hazardous waste (dependent
upon waste characteristics)
will be completed by
Contractor?

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 8 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, initial when
Special Program/Program Elements
but are not limited Applicable No or fully
to: N/A addressed
13. Work (b) Contractor ensures the
involving abrasive protection of adjacent grassy
blasting or gravel areas to facilitate
(continued from clean up and prevent
preceding page) contamination?
14. Work (a) Contractor ensures that
involving high operations will not generate
noise levels, >85 noise above the most stringent
dbA of applicable governmental
laws, regulations, local
ordinances, permits, and
approvals; applicable
Raytheon practices or
applicable Contractor
Practices?
(b) If noise levels are expected to
exceed 85 dbA, then
Contractor understands
responsibility for providing
notice to Raytheon-EHS and
addressing shielding and noise
reduction equipment?
15. Will the work (a) Contractor ensures the safe
generate waste or handling, storage and disposal
scrap materials? of the waste materials?
(b) Where “Hazardous/Regulated
Waste” is generated,
Contractor ensures that proper
storage, labeling,
manifest/transport and
treatment/disposal of the
waste will be performed?
(c) Copies of transportation, and
treatment or disposal records
shall be provided to Raytheon
Company?
16. Is there any (a) All employees have received
special training necessary training prior to the
required for the commencement of work?
nature of work to
be performed by
the Contractor?
(b) Upon request, Contractor
agrees to provide training
records to Raytheon-EHS or
designated Raytheon
personnel.

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 9 of 11

 Possible Work Indicate Contractor
Scenarios Include Check if Yes, initial when
Special Program/Program Elements
but are not limited Applicable No or fully
to: N/A addressed
17. General Contractor(s) agree(s) to:
Good Work
Practices
SHALL APPLY
TO ALL
PROJECTS
(a) Maintain a clean and orderly
work environment thereby
reducing associated hazards.
(b) Maintain floors clear of debris
and slipping hazards (e.g.,
grease, oil, liquids, etc.)
(c) Control and demarcate cords,
hoses and other facilities that
may run across the floor.
(d) Maintain clear aisle ways and
exits at all times.
(e) Clean up all debris at the end
of each work shift.
(f) Close containers of liquids and
other chemicals when not in
use.
(g) Store materials in areas
designated in the pre-work
planning meetings.
(h) Limit chemical storage inside
Raytheon Company facilities
to the amount to be used each
day. This is a special concern
where flammable or
combustible materials may
endanger high value
installations.

*** CHART CONTINUED ON NEXT PAGE ***

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 10 of 11

 Possible Work Special Program/Program Elements Indicate Contractor
Scenarios Include Check if Yes, initial when
(Please describe in detail the
but are not limited Applicable No or fully
“additional scenarios” not identified in
to: N/A addressed
Nos. 1 – 17, above)
18. Additional
Scenarios
(Identified by
Contractor)

19. Additional
Site-Specific
Scenarios or
Requirements
(Identified by
RAYTHEON
COMPANY).

ATTACHMENT EHS003 – POST CONTRACT AWARD (09/13) 11 of 11

 CONTRACTOR SUMMARY DATA AND SAFETY PROGRAM FORM
ATTACHMENT EHS004 (POST AWARD)

Contractor
Summary Data for Safety Program

I. GENERAL INFORMATION
1. CONTRACTOR 2. PURCHASE ORDER NUMBER 3. DATE

4. ADDRESS 5. SITE LOCATION

6. TELEPHONE

7A. SITE PHONE(S) 7B. SITE FAX

8. SITE SUPERINTENDENT 9A. MAXIMUM 9B. 9C. SHIFT

WORKERS/SHIFT SHIFTS/DAY TIMES

10. MAJOR EQUIPMENT CONTRACTOR WILL USE 11. MAJOR EQUIPMENT LOWER-TIER
CONTRACTOR(S) WILL USE

II. DESIGNATED SAFETY PERSONNEL

12. CONTRACTOR ON-SITE SAFETY 13. SAFETY REPRESENTATIVE’S TRAINING &
REPRESENTATIVE EXPERIENCE

14. PERSON(S) RESPONSIBLE FOR DAILY 15. PROVISIONS FOR DRINKING WATER &
HOUSEKEEPING SANITATION FACILITIES

16. PERSON(S) RESPONSIBLE FOR DAILY 17. SAFETY INSPECTOR’S QUALIFICATIONS &
SAFETY INSPECTIONS EXPERIENCE

18. PERSON(S) CERTIFIED IN FIRST-AID/CPR 19. CERTIFICATION TYPE / ISSUED BY /

EXPIRATION DATE

20. PERSON(S) CONDUCTING WEEKLY SAFETY 21. WEEKLY SAFETY MEETINGS (SCHEDULED
MEETINGS DAY/TIME)

ATTACHMENT EHS004 (POST AWARD) (09/13) 1 of 3

22. COMPETENT PERSONS (Identify names for each applicable specialty)
A. HAZARD ANALYSIS:
B. CONFINED SPACES:
C. EXCAVATIONS:
D. MATERIAL HANDLING/RIGGING:
E. CRANES:
F. SCAFFOLDS:
G. FALL PROTECTION:
H. ELECTRICAL POWER DISTRIBUTION
I. INSPECTION:
III. EMERGENCY SERVICES FOR THIS CONTRACT

23. # FIRST-AID KITS ON-SITE 24. NEAREST MEDICAL FACILITY/HOSPITAL

SERVICED BY? ADDRESS:

WHEN? PHONE #:

Note: You may need to coordinate with Security at some Raytheon Company sites to contact outside
emergency services for Item 25A-25C
25A. AMBULANCE 25B. FIRE DEPARTMENT 25C. POLICE

PHONE #: PHONE #: PHONE #:

IV. FIRE FIGHTING EQUIPMENT TO BE ON SITE

26A. EXTINGUISHERS, 26B. ANSI 26C. 26D. SPECIFIC LOCATION
TYPE CLASS/RATING QUANTITY

27.

ATTACHMENT EHS004 (POST AWARD) (09/13) 2 of 3

 V. HAZARDOUS/FLAMMABLE/COMBUSTIBLE MATERIALS ON SITE
THIS SECTION IS BRIEF SUMMARY ONLY; PER 29 CFR 1910.1200(e)(1)(i) CONTRACTOR SHALL HAVE
COMPLETE LIST AVAILABLE
28. FOR THIS SITE SDS TO BE AVAILABLE AT:

FORESEEABLE FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES

29A. MATERIAL/DESCRIPTION 29B. STORAGE LOCATION 29C. STORAGE CONTAINER

OTHER FORESEEABLE HAZARDOUS/TOXIC MATERIALS

30A. MATERIAL/DESCRIPTION 30B. STORAGE LOCATION 30C. STORAGE CONTAINER

31. CONTRACTOR’S NAME: (PRINT) 32. CONTRACTOR’S SIGNATURE: 33. DATE:

VI. SITE SPECIFIC CONTRACTOR SAFETY AND HEALTH PLAN

34. CONTRACTOR SHALL submit a SITE SPECIFIC SAFETY AND HEALTH PLAN for each project involving
high risk e.g., fall protection, confined space entry, energized work etc. AT THE TIME OF SUBMISSION
OF THIS COMPLETED CONTRACTOR SUMMARY DATA FOR SAFETY FORM.
35. THE CONTRACTOR SAFETY AND HEALTH PLAN AND SUPPLEMENTAL DOCUMENTATION (IF ANY)
SHALL, AT A MINIMUM, ADDRESS THE REQUIREMENTS SPECIFIED BY APPLICABLE FEDERAL,
STATE AND LOCAL LAWS, REGULATIONS, STANDARDS, POLICIES, AND/OR ORDINANCES and Job
Hazard Assessments and mitigation measures and equipment needed to ensure each project can be
performed safely.

ATTACHMENT EHS004 (POST AWARD) (09/13) 3 of 3