1. Contractors Safety Information Sheet Presented by: John Bollom Houston Business Roundtable 2010 Safety Excellence Award Training

2. Houston Business Roundtable 2010 Safety Excellence Award Training  Six Sections  Nominated By  Name of Firm  Type of Business  Company Description  OSHA Information  Contact Information 2009 CONTRACTORS SAFETY INFORMATION SHEET

3. Nominated by: ABC Chemicals *Note: If your firm has received several nominations, copy this form and complete one for each project site  Fill out one form for each project site you have been nominated for. Section 1: Nominated By

4. Name of your firm exactly as you wish it published on any brochures, plaques, etc.: Contact Name:Title: AddressCity/State/Zip Phone:Fax:e-mail:  Name of company as you would like to see it on awards.  Contact name needs to be someone that can answer questions. Section 2: Name of Firm

5. Type of business/work/service (check the one for which you want to be considered)  General Contractor Large (construction & maintenance)  Specialty Contractors – Hard Crafts (mechanical, I&E, HVAC)  Specialty Contractors – Soft Crafts Small (insulation, painting, scaffolding)  Specialty Contractors – Technical Support (engineering, safety, inspection)  General Contractor Small (construction & maintenance)  Specialty Contractors – Soft Crafts Large (insulation, painting, scaffolding)  Specialty Environmental (hydro blasting, vacuum trucks, chemical cleaning) Note: For Large and Small categories, placement may be changed based on company total hours  Check the category for which you want to be considered. Section 3: Type of Business

6. Company Description (Type of work/service your company does) _______________________________________________________________________________ _______________________________________________________________________________  Need a good description of work/service your company performs. Section 4: Company Description

7. Project/Work Site DataTotal Company Data a.Total number of OSHA recordable cases. b.Total number of lost work- day cases which involved days away from work. c.Total number of fatalities. d.Total hours worked. Use 2008 OSHA No. 300 logs to provide the following injury/illness data:  Data needed for both: Nominated worksite. Total company (All work in the US) Section 5: OSHA Information

8. SUBMITTED BY: ____________________________Title ______________________________ PHONE NUMBER: _____________________ E-MAIL:________________________________ Please return this form along with your HBR Safety Awards Initial Evaluation Form and the attachments checked off on the last page of that form to the Houston Business Roundtable, 8031 Airport Blvd., Suite 118 Houston, Texas\ 77061 by 4:00 p.m. on Monday, February 1, 2010  Contact name needs to be someone that can answer questions.  Make certain contact information is correct. Section 6: Contact Information

9. Safety Awards Initial Evaluation Form Houston Business Roundtable 2010 Safety Excellence Award Training

10. Houston Business Roundtable 2010 Safety Excellence Award Training Consist of a five page document 2009 Safety Awards Initial Evaluation Form

11. Safety Awards Initial Evaluation Form  Five Sections  General Information  Safety, Health & Environmental Performance  Safety, Health & Environmental Management  Safety, Health & Environmental Programs/Procedures  Information Submittal

12. Section 1: General Information GENERAL INFORMATION 1.Company Name:Telephone: Fax: Street Address: Mailing Address: Web site: Contact Person: e-mail: Telephone: Fax: 2. Parent Company Name:  Once again double check contact information. GENERAL INFORMATION 1.Company Name: Rohm and Haas Texas, IncTelephone: 281-228-8300 Fax: 281-228-8178 Street Address: 1900 Tidal Road Mailing Address: 1900 Tidal Road Maintenance Bldg Rm# 33 Deer Park, Texas 77536 Web site: www.rohmhaas.com Contact Person: John Bollom e-mail: jbollom@rohmhaas.com Telephone: 281-228-3415 Fax: 281-228-8178 2. Parent Company Name: Rohm and Haas Company

13. SAFETY, HEALTH & ENVIRONMENTAL PERFORMANCE 3.Workers Compensation Experience Modification Rate (EMR) Data b. EMR for three last years:  Interstate rate XXX Intrastate rate Monopolistic State rate Dual rate YR: 2007 EMR:.XXX YR: 2008 EMR:.XXX YR: 2009 EMR:.XXX c. State of Origin: Philadelphia, Pennsylvaniad. EMR Anniversary Date: XX/XX/XXXX e. Standard Industrial Code (SIC): 123456 4.Injury and Illness Data: a. Total company employee hours worked last three years (excluding subcontractors) Hours/ YearYR: FieldXXXX TotalXXXXX XXXXXX XXXXX Section 2: Safety, Health & Environmental Performance SAFETY, HEALTH & ENVIRONMENTAL PERFORMANCE 3.Workers Compensation Experience Modification Rate (EMR) Data b. EMR for three last years:  Interstate rate Intrastate rate Monopolistic State rate Dual rate YR: 2007 EMR: YR: 2008 EMR: YR: 2009 EMR: c. State of Origin: d. EMR Anniversary Date: e. Standard Industrial Code (SIC): 4.Injury and Illness Data: a. Total company employee hours worked last three years (excluding subcontractors) Hours/ YearYR: Field Total

14. Section 2: Safety, Health & Environmental Performance b. Provide data (excluding subcontractor) using your 300 Forms from the past three (3) years: Notes: (1) Data should be total company data unless specifically requested by client (2) Combine injuries and illnesses from 300 Form (3) If your company is not required to maintain OSHA 300 forms, please provide information from your Worker’s Compensation insurance carrier itemizing all claims for the last 3 years. YR: (4) If data is being provided after July 31 st please include current YTD cumulativeNo.RateNo.RateNo.Rate Fatalities Rate = Number of Fatalities x 200,000  Total Employee Hours Lost workday case injuries and illnesses involving days away from work, or days of restricted work activity, or both. Rate = Total LW and restricted cases x 200,000  Total Employee Hours b. Provide data (excluding subcontractor) using your 300 Forms from the past three (3) years: Notes: (1) Data should be total company data unless specifically requested by client (2) Combine injuries and illnesses from 300 Form (3) If your company is not required to maintain OSHA 300 forms, please provide information from your Worker’s Compensation insurance carrier itemizing all claims for the last 3 years. YR: 2009 YR: 2008 YR: 2007 (4) If data is being provided after July 31 st please include current YTD cumulativeNo.RateNo.RateNo.Rate Fatalities Rate = Number of Fatalities x 200,000  Total Employee Hours XX0.XX XX 0.XX XX 0.XX Lost workday case injuries and illnesses involving days away from work, or days of restricted work activity, or both. Rate = Total LW and restricted cases x 200,000  Total Employee Hours XX0.XXXX0.XX XX0.XX

15. Section 2: Safety, Health & Environmental Performance Lost workday case injuries and illnesses involving days away from work. Rate = LW cases** x 200.000  Total Employee Hours Injuries and Illnesses involving medical treatment only. Rate = Total Injuries and Illnesses involving medical treatment only x 200, 000  Total Employee Hours Total OSHA Recordable Injury and Illnesses Rate Rate = Total Injuries and Illnesses x 200,000  Total Employee Hours 5.Have you received any regulatory (EPA, OSHA, etc.), civil or criminal citations in the last three years? If yes, please attach copies.Yes No Lost workday case injuries and illnesses involving days away from work. Rate = LW cases** x 200.000  Total Employee Hours XX0.XX XX 0.XX XX 0.XX Injuries and Illnesses involving medical treatment only. Rate = Total Injuries and Illnesses involving medical treatment only x 200, 000  Total Employee Hours XX0.XX XX 0.XX XX 0.XX Total OSHA Recordable Injury and Illnesses Rate Rate = Total Injuries and Illnesses x 200,000  Total Employee Hours XX0.XX XX 0.XX XX 0.XX 5.Have you received any regulatory (EPA, OSHA, etc.), civil or criminal citations in the last three years? If yes, please attach copies.Yes No

16. Section 3: Safety, Health & Environmental Management SAFETY, HEALTH & ENVIRONMENTAL MANAGEMENT 6. Name of highest ranking Safety, Health & Environmental professional in the company: Name: Title: Certifications: Telephone: Fax: This person reports to: Title: 7. Do you have or provide: a. Full time Safety/Health Director Yes No b. Full time Site Safety/Health Supervisor Yes No c. Full Time Job Safety/Health Coordinator Yes No 8. Do you have or provide: a. Safety, Health & Environmental recognition program Yes No b. Company paid Safety, Health & Environmental training Yes No SAFETY, HEALTH & ENVIRONMENTAL MANAGEMENT 6. Name of highest ranking Safety, Health & Environmental professional in the company: Name: Safety Guru’s Name HERETitle: Boss Certifications: CSP, OHST, COSS Telephone: 123-456-7890Fax: 123-456-7890 This person reports to: Safety Guru’s BossTitle: Big Boss 7. Do you have or provide: a. Full time Safety/Health DirectorYes No b. Full time Site Safety/Health SupervisorYes No c. Full Time Job Safety/Health CoordinatorYes No 8. Do you have or provide: a. Safety, Health & Environmental recognition programYes No b. Company paid Safety, Health & Environmental trainingYes No

17. Section 4: Safety, Health & Environmental Programs/Procedures SAFETY, HEALTH & ENVIRONMENTAL PROGRAMS / PROCEDURES 9. a.Do you have a written S, H & E Program?Yes  No b. Does the program address the following key elements? 1. Management commitment and expectationsYes  No 2. Employee participationYes  No 3. Accountabilities and responsibilities for managers, supervisors, and employeesYes  No 4. Resources for meeting safety, health & environmental requirements.Yes  No 5. Periodic safety, health and environmental performance appraisals for all employeesYes  No 6. Safety, Health & Environmental Recognition Program Yes  No 7. Hazard recognition and control Yes  No c. Does the program satisfy your responsibility under the law for: 1. Ensuring your employees follow the safety rules of the facility?Yes  No 2. Advising owner of any unique hazards presented by the contractor’s work, and of any hazards found by the contractor? Yes  No

18. Section 4: Safety, Health & Environmental Programs/Procedures 10. Does the program include work practices and procedures such as: a. Equipment Lockout and Tagout (LOTO) Yes  No  N/A b. Confined Space Entry Yes  No  N/A c. Injury & Illness Recording Yes  No  N/A d. Fall Protection Yes  No  N/A e. Personal Protective Equipment Yes  No  N/A f. Portable Electrical/Power Tools Yes  No  N/A g. Vehicle Safety Yes  No  N/A h. Compressed Gas Cylinders Yes  No  N/A i. Electrical Equipment Grounding Assurance Yes  No  N/A j. Powered Industrial Vehicles (Cranes, Forklifts, JLGs, etc.) Yes  No  N/A

19. Section 4: Safety, Health & Environmental Programs/Procedures k. HousekeepingYes  No  N/A l. Accident/Incident ReportingYes  No  N/A m. Unsafe Condition ReportingYes  No  N/A n. Emergency Preparedness, including evacuation planYes  No  N/A o. Waste Disposal/Waste Minimization/Spill PreventionYes  No  N/A p. Back Injury PreventionYes  No  N/A q. Hazwoper TrainingYes  No  N/A r. Heat Stress PreventionYes  No  N/A s. EnvironmentalYes  No  N/A t. Scaffold Builing /Scaffold UseYes  No  N/A u. General NDT & RadiographyYes  No  N/A

20. Section 4: Safety, Health & Environmental Programs/Procedures 11. Do you have written programs for the following: a. Hearing ConservationYes  No  N/A b. Respiratory ProtectionYes  No  N/A Where applicable, have employees been: Trained Yes  No Fit tested Yes  No Medically approved Yes  No c. Hazard Communication Yes  No Have employees been trained Yes  No d. Program to support the contractor requirements of the OSHA Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents Standard (29 CFR 1910). Yes  No e. Spill prevention and waste minimization Yes  No

21. Section 4: Safety, Health & Environmental Programs/Procedures 12. Do you have a substance abuse program? Yes  No If yes, does it include the following?  Pre-placement Testing Yes  No  Random Testing Yes  No  Testing for Cause Yes  No  DOT Testing Yes  No  Post Incident Testing Yes  No  HASAP (Houston Area Substance Abuse Program) Yes  No 13. Do your employees read, write, and understand English such that they can perform their job tasks safely without an interpreter? Yes  No If no, provide a description of your plan to assure that they can safely perform their jobs.

22. Section 4: Safety, Health & Environmental Programs/Procedures 14. Medical a. Do you conduct medical examinations for:  Pre-placement Yes  No  N/A  Preplacement Job Capability Yes  No  N/A  Hearing Function (Audiograms) Yes  No  N/A  Pulmonary Yes  No  N/A  Respiratory Yes  No  N/A b. Describe how you will provide first aid and other medical services for your employees while on-site Specify who will provide this service: c. Do you have personnel trained to perform first aid and CPR? Yes  No

23. Section 4: Safety, Health & Environmental Programs/Procedures 15. Do you hold site safety, health and environmental meetings for: Field Supervisors Yes  No  Frequency Weekly Employees Yes  No  Frequency Daily New Hires Yes  No  Frequency Daily / As needed Subcontractors Yes  No  Frequency Are the safety, health and environmental meetings documented?Yes  No

24. Section 4: Safety, Health & Environmental Programs/Procedures 16. Personal Protection Equipment (PPE) a. Is applicable PPE provided for employees?Yes  No b. Do you have a program to assure that PPE is inspected and maintained?Yes  No c. Has a certified PPE assessment been completed?Yes  No 17. Do you have a corrective action process for addressing individual safety, health and environmental performance deficiencies? Yes  No

25. Section 4: Safety, Health & Environmental Programs/Procedures 18. Equipment and Materials: a. Do you have a system for establishing applicable health, safety, and environmental specifications for acquisition of materials and equipment? Yes  No  N/A b. Do you conduct inspections on operating equipment e.g., cranes, forklifts, JLGs) in compliance with regulatory requirements? Yes  No  N/A c. Do you maintain operating equipment in compliance with regulatory requirements? Yes  No  N/A d. Do you maintain the applicable inspection and maintenance certification records for operating equipment?Yes  No  N/A

26. Section 4: Safety, Health & Environmental Programs/Procedures 19. Subcontractors Do you use subcontractors? (If no, skip to question 43)Yes  No a. Do you use safety, health and environmental performance criteria in selection of subcontractors?Yes  No  N/A b. Do you evaluate the ability of subcontractors to comply with applicable safety, health and environmental requirements as part of the selection process? Yes  No  N/A c. Do your subcontractors have a written safety, health and environmental program? Yes  No  N/A d. Do you include your subcontractors in:

27. Section 4: Safety, Health & Environmental Programs/Procedures  Safety, Health & Environmental Orientation Yes  No  N/A  Safety, Health & Environmental Meeting Yes  No  N/A  Safety, Health & Environmental Inspections Yes  No  N/A  Safety, Health & Environmental Audits Yes  No  N/A 20. Inspections and Audits a. Do you conduct Safety, Health & Environmental inspections? Yes  No b. Do you conduct Safety, Health & Environmental program audits? Yes  No c. Are corrections of deficiencies documented? Yes  No

28. Section 5: Information Submittal INFORMATION SUBMITTAL Please provide copies of checked items if applicable to your company’s work EMR documentation from your insurance carrierSafety, Health & Environmental Training Schedule (Sample) Insurance Certificate(s)Safety, Health & Environmental Training for Supervisors (Outline) OSHA 200 and 300 Logs (Past 3 Years)Copy of Louisiana Contractor’s Licence Safety, Health & Environmental ProgramOrganization Chart Safety, Health & Environmental Recognition Program List of major equipment (e.g., cranes, JLGs, forklifts) your company has available for work at this facility.  Provide copies of checked items applicable to your company’s work.

29. Section 5: Information Submittal Substance Abuse Program (Include Substances Tested & Levels) Equipment Lockout and Tagout (LOTO) Hazard Communication ProgramConfined Space Entry Program Respiratory Protection ProgramFall Protection, Scaffold use, scaffold building Housekeeping PolicyPersonal Protective Equipment Accident/Incident Investigation ProcedurePortable Electric / Power Equipment Unsafe Condition Reporting ProcedureVehicle Safety Safety, Health & Environmental Inspection FormCompressed Gas Cylinders Program Safety, Health & Environmental Audit Procedure or FormElectrical Equipment Grounding Assurance Program

30. Section 5: Information Submittal Safety, Health & Environmental Orientation (Outline)Emergency Preparedness, including evacuation plan. Safety, Health & Environmental Training Program (Outline)Waste Disposal Program Example of Employee Safety, Health & Environmental Training Records Back Injury Prevention Program Workforce Skills Development PoliciesHeat Stress Prevention Program NDT & Radiography ProgramShort Service New Employee Program Brief description of your company’s “Best Practice(s)” and how they have improved your safety performance during past year. We have implemented a program that allows our employees to only work 2 days a week but produce 5 days of production by ………………. Who Filled Out This Information???  Need name and title of Company Officer responsible for accuracy of this document.

31. Overview Fill out Contractor Information Sheet for each project site that nominated you. Complete the Safety Awards Initial Form. Need copies of checked items applicable to your company’s work either: Electronic Copies (Disk) Hard Copies NO EMAILS! (Will not be accepted)

32. Overview Continued If submitting a disk make sure: Content is organized. Can open all material with a common program. Need hard copies of Information Sheet and Initial Evaluation Form with the disk.

33. Overview Continued Please submit all Information by: Hand delivering or, Mailing to: Houston Business Roundtable 8031 Airport Blvd. Suite 118 Houston Texas, 77061 By: 4:00 PM Monday Feb 1, 2010 NO EXCEPTIONS!

34. Houston Business Roundtable 2010 Safety Excellence Award Training