SPV Contractor Prequalification Questionnaire - Safety Aspect

SAFETY & HEALTH PERFORMANCE
1. Injury and illness Data:

a. Employee hours worked last three years (excluding subcontractors)
Hours/
year
Field
Total
b. Provide the following data (excluding subcontractor) using your forms from the past three (3) years:
Notes: (1) Data should be the best available data
2. Have you received any regulatory (Dinas Lingkungan Hidup, Depnaker etc.) citations in the last three
yeas? If yes, please attach copies
SAFETY & HEALTH MANAGEMENT

3. Highest ranking safety/ health professional in the company
Name/ Title: Telephone:
Email Address: Fax:
4. Do you have or provide:
a. Full time safety professional Yes No
5. a. Do you have a written Safety and Health Program/ Policy? Yes No
b. Does the program satisfy your responsibility under the law for
1. Ensuring your employees follow the safety rules of DEPNAKER? Yes No
2. Advising owner of any unique hazards presented by Yes No

the contractor's work, and of any hazards found by the contractor?
6. Do you have written programs for the following:
a. Equipment Lockout and Tagout Yes No N/A
b. Confined Space Entry Yes No N/A
c. Fall Protection Yes No N/A
d. Excavation/ Trench Yes No N/A
e. Personal Protective Equipment Yes No N/A
f. Electrical Safe Work Practices Yes No N/A
g. Powered industrial Vehicles (Cranes, Forklift, etc.) Yes No N/A
h. Accident/ Incident Reporting Yes No N/A
i. Asbestos Yes No N/A
j. Hazard communication Yes No N/A
k. Radiation Yes No N/A
7. Do you have a written substance abuse program? Yes No
If yes, does it include the following?
a. Pre-placement Training Yes No
b. Random Testing Yes No
c. Testing for Cause Yes No
SAFETY & HEALTH MANAGEMENT
8. Do you conduct safety meetings for your employee and sub contractor?
a. Are the safety and health meetings documented? Yes No
9. Fitness for Duty (Medical Check Up)
a. Do you have medical survelliance program for your employee Yes No
b. Do you have medical eximination for your employee prior job Yes No
execute?
10. Equipment and Materials:
a. Do you conduct inspections on operating equipment Yes No N/A
(e.g., cranes, forklifts) in compliance with regulatory
requirements?
b. Do you maintain operating equipment in compliance with Yes No N/A
regulatory requirements?
c. Do you maintain the applicable inspection and Yes No N/A
maintenance certification records for operating
equipment?
11. Subcontractors:
Do you use subcontractors? Yes No
(If no, skip to question 13)
a. Do you use safety and health performance criteria in Yes No N/A
selection of subcontractors?
b. Do you evaluate the ability of subcontractors to comply Yes No N/A
with applicable health and safety requiremants
as part of the selection process?
c. Do your subcontractors have a written Safety Yes No N/A
and Health Program?
d. Do you include your subcontractors in:
- Safety and Health Orientation Yes No N/A
- Safety and Health Meeting Yes No N/A
- Inspections and Audits Yes No N/A
12. Inspections and Audits

a. Do you conduct safety and health inspections? Yes No
b. Do you conduct safety and health program audits? Yes No
c. Are corrections of deficiencies documented? Yes No

SAFETY & HEALTH TRAINING
13. Safety and Health Orientation
New Hires Supervisors
a. Do you have a Safety and Health Orientation Yes No Yes No
Program for new hires and newly hired or
promoted supervisors?
b. How long is the orientation program? hours
c. Are written exams given? Yes No
(written test, Performance Test, Job Monitoring, Other-List)
If no, how do you verify comprehension?
d. How many employees do you have that are AK3 trained?
e. How many employees do you have that are Confined Space competent person trained?
f. How many employees do you have that are Scaffold competent person trained?
g. How many employees do you have that are Radiation competent person (PPR) trained?
h. Please list any other special training here:
INFORMATION SUBMITTAL
14. Questionnaire completed by:
Name: Telephone:
Title: Cell phone number:
Email address: Fax:
Please provide copies of the following with the completed CPQ:
a. Safety and Health Program, Safety and Health Inspection Form, Safety and Health Orientation (Outline)
b. Safety and Health Training Program (Outline), Example of Employee Safety and Health Training Records
c. Safety and Health Training Schedule (sample)
d. Safety and Health Training for Supervisors (Outline)
e. Other
Note: This questionnaire and accompanying documents shall not be construed to constitute a commitment by
the client to request contractor to perform any work or create an exclusive right of contractor to provide work
with respect to any project or limit client's right to retain other contractors.
Upon completion, please sign, date and return this document and attachments to PT South Pacific Viscose
Signature ___________________________________
Printed Name ___________________________________

SPV Contractor Prequalification Questionnaire - Safety Aspect

Uploaded by

Copyright:

Available Formats

SPV Contractor Prequalification Questionnaire - Safety Aspect

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

SPV Contractor Prequalification Questionnaire - Safety Aspect

Uploaded by

Copyright:

Available Formats

SAFETY & HEALTH PERFORMANCE

1. Injury and illness Data:

SAFETY & HEALTH MANAGEMENT

1. Ensuring your employees follow the safety rules of DEPNAKER? Yes No

2. Advising owner of any unique hazards presented by Yes No

12. Inspections and Audits

b. Do you conduct safety and health program audits? Yes No

c. Are corrections of deficiencies documented? Yes No

You might also like