part a: proposal - web viewproponents are to answer all the questions below in order for their...

APPENDIX C: PROPOSAL SUBMISSION TEMPLATE

Introduction and Scoring

This Proposal Submission Template must be completed and submitted as part of the Proponent’s Proposal submission. It consists of:

Part A: ProposalPart B: Proponent Safety Program DescriptionPart C: Additional Information (optional)

Proponents are to answer all the questions below in order for their Proposal submission to advance to the evaluation stage. Please note that simply answering all questions does not necessarily mean that full points will be awarded to the Proponent for the section.Proposals will be evaluated for Best Value, not just best price. In all of its procurement purchases, the Purchaser aims to advance its objectives while maintaining an optimum balance between cost and non-cost factors. Proposals will be evaluated based on the following categories and weights:Evaluation Category WeightMandatory Requirements Pass/FailQualifications and General Experience 20%Proposed Plan: Service Delivery and Project Management 20%Pricing 25%Building the Energy Efficiency Industry and Local Economy in NS 20%Interview1 15%Total 100%

Using this Proposal template All references to “you” and “your” in the questions below refer to the Proponent. All references to “we”, “our” and “us” refer to the Purchaser.If your Proposal includes more than one region and any of your answers below differ from one region to another, please clearly indicate the differences within your responses. In some cases, the Purchaser explicitly requests separate responses for each region in your Proposal. To use this template, simply click in the text boxes where indicated and type or click in a check box to mark your selection. You will not be able to modify anything else in the file except in Part C “Additional Information”. There are no limits on the text you provide. While you are encouraged to provide clear and concise responses, Proposals with inadequate detail to demonstrate a full understanding of the service and relevant experience will be assigned 1 Interviews will occur in early to mid April for qualifying proponents.

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lower scores. Similarly, Proposals that do not fully respond to all components of each question will be assigned lower scores. Part C “Additional Information” provides a space for you to tell us anything else about you or your experience that would be helpful for the Purchaser to know. Completing this section is optional and anything you include here may be factored into the scoring categories above.

of 24RFP No. 2018-0090: Appendix C – Proposal Submission Template

Part A: Proposal Qualifications and General ExperienceThe Purchaser is looking for organizations with qualifications and demonstrated experience to deliver a high-quality service to its participants. 20 points of 100 will be allocated to this section.

1. Your organizationThe Purchaser requires one organization (per region) to be identified as the lead organization that will act as the primary contact for all First Nations Home Energy Efficiency Pilot related accountabilities and hold overall responsibility for achieving service deliverables. The Purchaser considers this lead organization to be the “Proponent” and if successful, this is the organization that will negotiate and enter into a resultant contract with the Purchaser.

Organization name: Click here to enter text.Address: Click here to enter text.Primary Contact Name: Click here to enter text.Primary Contact Phone: Click here to enter text.Primary Contact Email: Click here to enter text.a) Describe your understanding of the roles, responsibilities and tasks you

will be responsible for under this pilot program. Also detail what region(s) of the Province you are seeking to become a Delivery Agent. Click here to enter text.

b) Tell us about your previous experience delivering related services. This could include, but is not limited to, delivering other target-driven programs and services, working with an administrator, working closely with partners or subcontractors, or managing a large number of projects simultaneously. Include a summary of your performance in delivering such services.Click here to enter text.

c) If not addressed above, tell us about your previous experience performing the following activities. Proponents are encouraged to describe their performance for each.

performing EnerGuide home evaluations; of 24

RFP No. 2018-0090: Appendix C – Proposal Submission Template

working with subcontractors; providing training; identifying opportunities for energy efficiency upgrades; or managing major portions of the service such as overall project

management or project administration.Click here to enter text.

2. Key partner organizations and key subcontractorsIntroduce your key partner organizations and subcontractors, if applicable. A key partner or key subcontractor is defined as an organization besides your own that is responsible for at least one of the following:

performing EnerGuide home evaluations; working with subcontractors; providing training; identifying opportunities for energy efficiency upgrades; or managing major portions of the service such as overall project

management or project administration. If you have fewer than four key partners and subcontractors, you do not need to complete all descriptions below.

Partner/Subcontractor 1Organization name: Click here to enter text.Address: Click here to enter text.a) Describe the roles, responsibilities and tasks this partner/subcontractor

will be responsible for.Click here to enter text.

b) Regions of First Nations Home Energy Efficiency Pilot operation.Click here to enter text.

c) Previous experience in similar roles, responsibilities and tasks in (a) above.Click here to enter text.


will be responsible for. of 24


Click here to enter text.











Other partners/subcontractorsIf you have more than four key partners and subcontractors, please use this space to include the same information as above.


3. Project Team


For clarification, please indicate the key Project Team members regardless of the organization they work for, which will be assigned to the Purchaser’s project team that will be responsible for the following roles/duties.

a) Energy Advisor(s): Perform EnerGuide home evaluation using Natural Resources Canada’s (NRCan) EnerGuide Rating System Version 15 and identify opportunities for energy efficient upgrades;Click here to enter text.

b) Project Manager: Individual that will be recommending and overseeing completion of upgrades (if different than the Energy Advisor) and submitting scope of work documents to the Purchaser; Click here to enter text.

c) Quality Assurance: Individual performing quality assurance verification on the upgrades (if different from the roles outlined above); andClick here to enter text.

d) Main point of contact: Individual that acts as the main contact between the Delivery Agent, the Purchaser, First Nations, and the third-party contractors. This individual will also be accountable for making decisions on behalf of the proponent.Click here to enter text.

Note: These are the individuals that will be interviewed (if the Proponent is shortlisted). They must be the same individuals as identified above. No substitutes, or proxies, will be allowed.

4. Building science experienceIn order to propose effective energy efficient solutions to participant homes under the First Nations Home Energy Efficiency Pilot, a strong building science background is needed. a) What organization will be proposing upgrades to the Purchaser (i.e.

submitting recommended upgrades and their associated price quote for each home)?Click here to enter text.


b) Please describe relevant training, experience and knowledge of building science and how you and your partners/subcontractors plan to use these skills in order to effectively and safely propose and install upgrades in participant homes.Click here to enter text.

5. Natural Resources Canada (NRCan) license to conduct EnerGuide Home Evaluations for existing homesThe Purchaser requires that all EnerGuide home evaluations performed under First Nations Home Energy Efficiency Pilot are conducted by NRCan approved registered Energy Advisors. a) Attach documentation to demonstrate that the organization tasked

with performing EnerGuide home evaluations is licensed with NRCan to perform EnerGuide home evaluations for existing homes.

I have attached the required documentation: and provided the file(s) location/file name in the response to Question 7, table item #4: Yes ☐ No ☐

b) Provide a list of registered Energy Advisor identification numbers registered for use with NRCan that will be used for First Nations Home Energy Efficiency Pilot EnerGuide home evaluations.Click here to enter text.

c) Tell us about any additional qualifications or experience your organization or your Energy Advisors have that will enable them to conduct high quality EnerGuide home evaluations. If one of your partners or subcontractors will conduct D and E energy assessments, tell us about any of their additional qualifications or experience.Click here to enter text.

6. ReferencesList at least two references that can speak to your previous related experience. Also include a minimum of two references for each key partner and subcontractor identified in question 2 above. Include a name, title, organization, phone number, email address and relationship to the Proponent or partner/subcontractor. The Purchaser reserves the right to check additional references, at their sole discretion, and not just those provided by the Proponent.



7. Potential conflicts of interestFully disclose possible conflicts of interest, actual and perceived, which could arise in connection with this RFP or the Proponent’s delivery of the First Nations Home Energy Efficiency Pilot on behalf of the Purchaser. Describe how these conflicts will be resolved.Click here to enter text.

8. Mandatory RequirementsProponents must provide the following as part of their Proposal submissions. NOTE: Failure to include these mandatory requirements may result in a Proponent’s Proposal submission being rejected without further consideration:

Requirement

Documentation included in Proposal submission? -OR- Response to question

Location / file name of documentation

1. All questions in Part A of this Appendix C are answered Yes ☐ No ☐ n/a

2. All items/questions in Part B of this Appendix C have been completed Yes ☐ No ☐ n/a

3. Completed Schedule of Prices (Appendix E) with all mandatory prices provided Yes ☐ No ☐ Click here to enter

text.4. Documentation of Proponent (or partner/

subcontractor) NRCan license to conduct EnerGuide home evaluations for existing homes

Yes ☐ No ☐ Click here to enter text.

5. Proof of Commercial General Liability Insurance, not less than $2 million Yes ☐ No ☐ Click here to enter

text.6. Proof of automobile liability insurance for

owned and non-owned vehicles, not less than $2 million;


7. Proof of Nova Scotia Workers’ Compensation Board (WCB) coverage (if out of province, equivalent coverage)


8. Financial disclosure: A copy of the Proponent company’s most recent financial statements2 Yes ☐ No ☐ Click here to enter

text.9. Do you accept the standard terms and

conditions as stated in Attachment 1?Yes ☐ No ☐ If “No” provide any/all

requested changes

2 Note: The Purchaser will accept the Proponent’s most current financial statements, audited or unaudited. The Purchaser reserves the right to ask additional questions and request additional information as related to the financial health of a Proponent’s organization and that of their key partner organizations and key subcontractors.


Requirement

Documentation included in Proposal submission? -OR- Response to question

Location / file name of documentation


Service Delivery and Project ManagementThe following questions provide an opportunity to describe your proposed plan to deliver the service. 20 points of 100 will be allocated to this section.

Anticipated regional participation is described below, which is subject to change at the Purchaser’s discretion. Please note that participant numbers below represent completed participants. Proponents should reference the First Nations Home Energy Efficiency Pilot Guidelines (Appendix B) for details on what constitutes a completed participant. This table is to be used to describe some aspects of your work plan below.

Figure 1: Delivery Agent Regions

Region First Nations Communities Estimated Participating Homes

Region 1

EskasoniMembertouPotlotekWagmatcookWaycobah Paq'tnkekPictou Landing

141166966

Region 2

AcadiaAnnapolis ValleyBear RiverGlooscapMillbrookSipekne'katik

55551111

TOTAL 100

9. RegionsThe Purchaser’s preference is to award contracts according to the pre-defined regions above. List the region(s) you are offering on as part of your Proposal submission. If you are offering on an area(s) that is smaller than, or does not align with, the pre-defined regions and their associated boundaries, you must


clearly define the area(s) you are offering on and explain why you have proposed this area(s) versus the pre-defined regions.Click here to enter text.

10.Service operation hoursThe Purchaser expects Delivery Agents to offer the service to participants for at least 40 hours per week. List the days of the week and hours of operation that you will offer the service to participants. Please also indicate what, if any, flexibility you will be providing in your schedule to accommodate participants with unusual schedules. If it differs in different regions within your Proposal, please indicate the specifics in your response.Click here to enter text.

11.Work planIn this section, the tables “Work Plans” are provided to help you tell us about your work plan(s) for the regions you are interested in working. Please consider the following assumptions and considerations:

Estimated participant completion targets by region are described at the beginning of this section. You should use these estimates as a basis for your work plan. The total number of E Assessments should equal the total number of anticipated regional participant completion targets in Figure 1 – Delivery Agent Regions, above. If you are proposing working in a smaller area than the regions defined above, please clearly indicate this in your explanation in (b), below, to enable the Purchaser to better understand your work plan.

Not all participants who receive a D Assessment will follow through with upgrades for various reasons. Assume a 90% completion rate (e.g. for every 100 participants who receive a D Assessment, only 90 will receive upgrades. This means that you will have to complete more D Assessments than the regional participant target.).

Assume a 2-week turnaround from Upgrade Spec Sheet submission to Upgrade Spec Sheet approval (refer to First Nations Home Energy Efficiency Pilot Draft Guidelines for details on Upgrade Spec Sheet approval process).

Assume that Purchaser – Delivery Agent contracts are signed and all required Delivery Agent training is complete by May 8, 2018.

Assume that the Purchaser provides a sufficient quantity of participants to reach targets in each region/area.


a) Complete the applicable number of tables below. Two (2) work plan tables are provided but you must only complete one table for each region/area you wish to work. This in no way guarantees that successful Proponents will be awarded the total number of participants in each work plan.

Work Plan for Region 1Region: Click here to enter text.

Date# D

Assessments completed

# Upgrade Spec Sheets submitted to Purchaser for

approval that contain upgrades (see assumption

about non-completion rate)

# Participants

with all upgrades completed

# E Assessments completed

May 8-31, 2018

Jun 1-30, 2018

Jul 1-31, 2018

Aug 1-31, 2018

Sept 1-30, 2018

Oct 1-31, 2018

Nov 1-30, 2018

Dec 1-31, 2018

Jan 1-31, 2019

Feb 1-28, 2019

Mar 1-31, 2019

TOTAL


Work Plan for Region 2

Region: Click here to enter text.

Date# D

Assessments completed

# Upgrade Spec Sheets submitted to Purchaser for

approval that contain upgrades (see assumption

about non-completion rate)

# Participants

with all upgrades completed

# E Assessments completed

May 8-31, 2018

Jun 1-30, 2018

Jul 1-31, 2018

Aug 1-31, 2018

Sept 1-30, 2018

Oct 1-31, 2018

Nov 1-30, 2018

Dec 1-31, 2018

Jan 1-31, 2019

Feb 1-28, 2019

Mar 1-31, 2019

TOTAL

b) Expand on the work plan(s) described above. Tell us about the reasons why your plan(s) looks the way it does (for example, tell us if you have considered factors such as winter weather, ramp up time, scheduling issues, etc.). Explain how you would respond to unexpected changes in your work plan(s) (e.g. increase or decrease in targets as directed by the Purchaser, unanticipated equipment failures that put you behind target, etc.). The intent of this question is not to try to predict the unexpected but rather, to demonstrate the level of flexibility you have to accommodate changes.



12.ResourcesComplete the table below to tell us about the resources that you and your partners/subcontractors have or would acquire in order to achieve the participant completion targets in the region(s)/area(s) of your Proposal. Please include all proposed regions/areas of your submission in the table below. If you will be sharing or shifting resources between regions, please clearly indicate this. There are no limits on the number of other resources you can tell us about.

Region(s) – please include all regions in your Proposal:Click here to enter text.

Resource Number of resources

Base location of resources

Regions the resources

will serviceAdditional notes

(optional)

Registered Energy Advisors

Click here to enter

text.

Click here to enter

text.

Click here to enter

text.Click here to enter text.

Office/ admin/ management staff

Click here to enter

text.

Click here to enter

text.

Click here to enter


Other (please specify type of resource - e.g. quality assurance staff)

Click here to enter

text.

Click here to enter

text.

Click here to enter


13.Key PersonnelIdentify your current staff that would be working on this pilot. Please also include their positions. Where applicable, please also include this information for any partner organizations. Click here to enter text.

14.Ramping upIf you plan to acquire new staff and resources, please describe your plans and timelines for ramping up. If you do not need to acquire new staff and resources, describe how you will make use of existing staff to deliver the service.Click here to enter text.

This section offers you an opportunity to demonstrate that you understand and have considered all pieces of the First Nations Home Energy Efficiency Pilot. Managing the First Nations Home Energy Efficiency Pilot at both the


service administration level and the project management level are key components of service delivery. Successful Proponents will have a strong plan in place to manage all aspects of the First Nations Home Energy Efficiency Pilot. The Purchaser expects the participant to be at the forefront of all service delivery plans.

In your answers below, you will have the opportunity to describe your approach to managing the service and highlight your past management experience. Proponents are encouraged to highlight how their plans will keep inconveniences for participants low and participant satisfaction levels high.

15.Customer serviceDescribe your customer service procedures. Include an explanation of how complaints will be documented, handled, resolved and communicated with the Purchaser. Proponents are encouraged to use examples and relevant experience to illustrate their processes.Click here to enter text.

16.Vermiculite testingMany homes in NS contain vermiculite insulation and in some cases this vermiculite contains asbestos. In order to determine if it is safe to insulate in these homes, the Purchaser will cover the costs of testing vermiculite for asbestos. The Purchaser requires that Delivery Agents follow the method outlined in the First Nations Home Energy Efficiency Pilot Guidelines for vermiculite testing. Please describe how you will conduct this testing: who will take samples, the qualifications they have, where samples will be sent, what test methods will be employed, and estimated timelines for receiving results.Click here to enter text.

17.Confirming Contractors are well Suited to Complete UpgradesDescribe your proposed approach to ensuring contractors are well suited to complete upgrades that align with the pilot Guidelines (Appendix B). Please include estimated time required for this approach. Click here to enter text.

18.Secondary Responsibility – EnerGuide Home Evaluation TrainingDescribe your proposed approach to each of the three options related to training community members on EnerGuide home evaluation, as per


section 4.2.2 in the RFP. Please include estimated time required for this approach. Click here to enter text.

19.General managementDetail your and your partners’/subcontractors’ approach for general service management. Proponents are encouraged to describe previous relevant experience from which they will draw in order to ensure high level management of the service. Your responses should include, at minimum, the following:

a description of the resources you will dedicate to managing the overall service;

how you will handle the collection and storage of data; and how you will handle service administration and paperwork.

Note that the Purchaser will require Delivery Agents to use the Purchaser’s templates for most aspects of program delivery and data sharing, as specified in the First Nations Home Energy Efficiency Pilot Draft Guidelines. Most templates are in Microsoft Excel and Microsoft Word formats. Files will often be shared via Microsoft SharePoint or another online file-sharing service.Click here to enter text.

20.Participant target managementFirst Nations Home Energy Efficiency Pilot is a target-driven service. Describe how you will manage your participant targets and how you will ensure that you achieve your targets and stick to the work plan you have provided. Summarize previous relevant experience and the strategies you would implement to get back on track if you fall behind your targets.Click here to enter text.

21.Project managementProject management is an important aspect of service delivery. Delivery Agents are expected to manage all projects (act as primary point of contact for participants, schedule appointments, discuss approved work with participants, oversee quality work completed by contractors, follow up with participants as required, and complete energy assessments). High quality customer service is a high priority for the Purchaser.


a) Describe your approach to managing projects under First Nations Home Energy Efficiency Pilot. If project management responsibilities are shared between more than one partner/subcontractor in your Proposal, define each group’s roles.Click here to enter text.

b) Tell us about your previous relevant experience managing projects and overseeing work completed by other contractors. How will you use this experience to deliver the First Nations Home Energy Efficiency Pilot?Click here to enter text.

22.Partner/Subcontractor collaborationIf you are partnering with other organizations, describe how your organizations will work together to ensure that participant targets are met, and high-quality work is performed (e.g. communications strategies, joint activities, data sharing, etc.). Proponents are encouraged to describe past experience working with the partners and subcontractors named in your Proposal.Click here to enter text.

23.Quality assuranceDelivery Agents must ensure that home upgrades completed by contractors hired by First Nations communities are quality upgrades that meet pilot Guidelines. Describe your proposed approach to ensuring quality upgrades. Click here to enter text.

24.InnovationProponents are also encouraged to identify additional value they can provide to EfficiencyOne, in relation to its business, outside of traditional services.

Describe any proposed Innovations or Value Add initiatives that you would like to offer the Purchaser for its consideration. Identify the additional costs or cost savings (if any) associated with these proposed Innovations and/or Value Add initiatives.



Pricing25 points of 100 will be allocated to this section.

25.Pricing scheduleProponents must submit, in MS Excel format, their Schedule of Prices using the template provided in Appendix E of the RFP. You may submit a different Schedule of Prices for each region you are offering on as part of your submission, or indicate the regions to which your pricing applies. Pricing cannot vary within a single region.

I have attached the required MS Excel pricing file(s) and provided the MS Excel file(s) location/file name in the response to Question 7, table item #3: Yes ☐ No ☐

Building the Energy Efficiency Industry and Local Economy in Nova Scotia Building the energy efficiency industry and the local economy in Nova Scotia are high priorities for the Purchaser. 20 points of 100 will be allocated to this section. Your score may incorporate responses from some questions above as related to building the energy efficiency industry and Nova Scotia content. Please refer to section 8.2 “Building the Energy Efficiency Industry and Local Economy” of the RFP for additional guidance on the questions below.

26.Building the Energy Efficiency Industry in Nova ScotiaDescribe how your and your partners’ organizations are advancing Nova Scotia’s energy efficiency industry. See section 8.2.1. of the RFP document for additional guidance. Click here to enter text.

27.Promoting economic growth/development within Nova Scotia Describe how your and your partners’ organizations are investing your revenue in the Nova Scotian economy. This may include a description of how you will provide employment for the labour force of Nova Scotia; the number of fulltime and part-time Nova Scotian staff who will be employed directly by your services; the percentage of the total cost of the services provided that will remain in Nova Scotia (e.g. 80% of the $XX.00/ fee per unit will remain in Nova Scotia). Click here to enter text.


Part B: Proponent Safety Program Pre-Qualification FormThe Purchaser values health and safety and has developed this form to better understand each Proponent’s current status with respect to health and safety practices and procedures. This is a standard part of all of the Purchaser’s procurement processes. The Purchaser does not require that Proponents have all of the health and safety programs/practices/procedures in place for their Proposal to be successful. However, the Purchaser will use this form to assess associated risks and inform decisions. The Purchaser may request as a condition of award that the Proponent commit to working toward putting certain applicable programs and procedures in place.

Company Identification1. Company Name: _____________________________________________

Telephone: _____________________________________________

Fax: _____________________________________________

Contact: _____________________________________________

Email: _____________________________________________

Mailing Address: _____________________________________________

2. Form of Business:☐ Sole Owner ☐ Partnership ☐ Corporation

3. Insurance Carrier(s):Name: Type of Coverage: Telephone:

4. Are there any judgments, claims or suits pending or outstanding against your company?

☐Yes ☐No

5. Have you received any regulatory or compliance ☐Yes ☐No of 24


orders and/or prosecutions in the last 3 years from the Department of Labour?

6. Do you have Nova Scotia Worker’s Compensation Board (WCB) coverage (if out of province, equivalent coverage)?

☐Yes ☐No

(a) If “Yes”, did you provide proof of coverage in your submission?

☐Yes ☐No

7. Do you have “WCB Safety Certified” accreditation? (Please note this is not the same as WCB coverage)

☐Yes ☐No

(a) If “No”, do you commit to taking the necessary steps to achieve “WCB Safety Certified” accreditation should the Purchaser select you as a successful Proponent?

☐Yes ☐No

(b) Do you commit to undergo a “WCB Safety Certified” audit, should you be a successful Proponent, within three to six months of the effective date of an Agreement, and demonstrate that reasonable steps are being taken to achieve and or maintain “WCB Safety Certified” accreditation?

☐Yes ☐No

8. Do you accept responsibility for ensuring that all employees, sub-contractors, sub-suppliers, agents and representatives under your direction comply with all federal, provincial and municipal health, safety and environmental statutes, regulations, policies, and guidelines?

☐Yes ☐No

Safety & Health Program and Procedures9. Do you have a written Health & Safety Policy? ☐Yes ☐No10.Do you have a written Health & Safety Program? ☐Yes ☐No11.Does the program address the following key

elements?(a) Management commitment and expectations ☐Yes ☐No(b) Employee participation ☐Yes ☐No(c) Accountabilities & responsibilities for managers,

supervisors, and employees☐Yes ☐No

(d) Resources for meeting safety and health requirements

☐Yes ☐No


(e) Periodic safety and health performance appraisals for employees

☐Yes ☐No

(f) Hazard recognition and control ☐Yes ☐No

12.Does the program include work practices and proceduressuch as:(g) Equipment Lockout and Tag-out (LOTO) ☐Yes ☐No(h) Confined Space Entry ☐Yes ☐No(i) Fall Protection ☐Yes ☐No(j) Personal Protective Equipment ☐Yes ☐No(k) Portable Electrical / Power Tools ☐Yes ☐No(l) Vehicle Safety ☐Yes ☐No(m) Compressed Gas Cylinders ☐Yes ☐No(n) Electrical Equipment Grounding Assurance ☐Yes ☐No(o) Powered Industrial Vehicles (Cranes, Forklifts,

etc.)☐Yes ☐No

(p) Housekeeping ☐Yes ☐No(q) Accident / Incident Reporting ☐Yes ☐No(r) Unsafe Condition Reporting ☐Yes ☐No(s) Emergency Preparedness, including Evacuation

Plan☐Yes ☐No

(t) Waste Disposal ☐Yes ☐No(u) Respiratory Protection ☐Yes ☐No(v) Designated Substance Management ☐Yes ☐No

13.Do you have a policy for the termination of contracts of subcontractors who do not comply with the Occupational Health & Safety Act and Regulations and/or Company Rules and Policies?

☐Yes ☐No

14.Do your employees read, write and understand English such that they can perform their job tasks safely without an interpreter? (If no, provide a description of your plan to assure that they can safely perform their jobs.)Click here to enter text OR print and write below

☐Yes ☐No


15.Medical(a) Do you have personnel certified in Standard

Care First Aid?☐Yes ☐No

(b) Do you have an emergency plan in place? ☐Yes ☐No(c) Are First Aid Kits provided? ☐Yes ☐No

16.Personal Protective Equipment (PPE)(a) Is application PPE provided for employees? ☐Yes ☐No(b) Do you have a program to assure that PPE is

inspected and maintained?☐Yes ☐No

(c) Are employees trained in PPE use? ☐Yes ☐No17.Do you have corrective action process for

addressing individual safety and health performance deficiencies?

☐Yes ☐No

18.Equipment & Manuals(a) Do you conduct inspections on operating

equipment (e.g. cranes, forklifts, etc.) in compliance with regulatory requirements?

☐Yes ☐No

(b) Do you maintain operating equipment in compliance with regulatory requirements?

☐Yes ☐No

(c) Do you maintain the applicable inspection and maintenance certification records for operating equipment?

☐Yes ☐No

(d) Are records available upon request? ☐Yes ☐No19.Subcontractors

(a) Do you use safety and health performance criteria in selection of subcontractors?

☐Yes ☐No

(b) Do all of your subcontractors have a written health and safety program? If some do and some do not, please provide more detail.Click here to enter text OR print and write below

☐Yes ☐No

(c) Do you include your subcontractors in: Safety and Health Orientation ☐Yes ☐No Safety and Health Meetings ☐Yes ☐No Inspections ☐Yes ☐No Audits ☐Yes ☐No

20.Safety & Health Training of 24


(a) Do you know the regulatory safety and health training requirements for your employees?

☐Yes ☐No

(b) Have your employees received the required safety and health training and retraining?

☐Yes ☐No

(c) Do you have a specific safety and health training program for supervisors?

☐Yes ☐No

21.Job Skills(a) Have employees been trained in appropriate job

skills?☐Yes ☐No

(b) Are employee job skills certified where required by regulation or industry standards?

☐Yes ☐No

(c) Are certificates available upon request? ☐Yes ☐No22.Training Records

(a) Do you keep safety, health, and job skills training records for employees?

☐Yes ☐No

(b) Are records available upon request? ☐Yes ☐No23.Does your Occupational Health and Safety Plan

meet or exceed the minimum requirements of Nova Scotia’s OH&S Act?

☐Yes ☐No

(a) If “No”, do you commit to taking the necessary steps to meet those requirements should the Purchaser select you as a successful Proponent?

☐Yes ☐No

I agree that the information in this Proponent Safety Program Pre-Qualification Form is true and correct to the best of my knowledge. I also agree to provide EfficiencyOne with documentation in relation to information described herein if requested.

Name (please print):

Title:

Signature3: Date:

3 Signature is to be that of an individual with the authority to bind the proponent. Electronic signatures are permitted.


Part C: Additional Information (optional)This section is provided as additional space for you to include additional information about you, your partner(s) and/or subcontractor(s), your experience, or anything else you would like to include to support your Proposal. Any additional information provided in this section may be used to help determine scores for each of the categories above. You are not restricted on what or how much additional information you include here. Completing this section is optional.


part a: proposal - web viewproponents are to answer all the questions below in order for their...

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