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FORM 10

HSE requirements

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9 views

FORM 10

HSE requirements

Uploaded by

layeeqit57
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM 10: HEALTH & SAFETY

A. Health & Safety

1. Does your company have a documented and current Health and Safety Policy
Statement, endorsed by senior management and reviewed within the last 12 months?
If yes, please provide a copy.
2. Does your company have a health and safety management system (HSMS) certified by
a 3rd party to ISO 45001? If yes, please provide a valid copy of the certificates. If this is
a joint venture, are all the companies accredited?
3. Does your company have a health and safety operating procedures manual? If yes
please provide a document outlining the content of this manual detailing the latest
revision date. What are your health and safety performance objectives, goals and
targets? And how are they monitored and measured? Please provide details.
4. Does your company have a structured organization chart identifying those with key
Health, Safety and Welfare responsibilities? If yes, please attach, along with the CV of
the nominated HS representative.
5. Do you have a process for selecting & qualifying your subcontractors / suppliers for
health and safety performance? Please provide details.
6. Does your company have a procedure for Activity Hazard Analysis and daily pre-task risk
control processes? If yes please provide a completed sample for both.
7. Do your directors, management, supervision and workforce attend health and safety
training? If yes, please provide a copy of your health and safety training needs, analysis
plan and training matrix.
8. Does your company carry out health and safety monitoring, inspections and audits to
determine compliance to regulations and procedures? If yes, who conducts them and
how often? How are actions communicated and closed out? Please provide details.
9. Complete the following table in regard to your Company’s health and safety record:
1. Accident and Incident Data :
a. Company
employee
hours worked Hours / Year 2018 2019 2020 2021 2022 2023
last three
years
A1 Employees
A2 Subcontractors
A3 Total
b. Provide the following 2018 2019 2020 2021 2022 2023
information from for the last 6
years. (Company and
subcontractor)
No. No. No. No. No. No.

Civil or criminal citations in relation


to HS infringements
Fatalities
1) Serious (Major) Injuries
(inclusive of fatalities)

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2) Lost Time Injury (Over 3 day
Injuries)
3) Minor accidents (Medical
Treatment/Restricted Work
Case/First Aid)

4) Incidents (non –injury events,


including near misses and
dangerous occurrences)
5) Occupational Health Cases
1 Total Events (1+2+3+4+5)
Lost Time Frequency Rate
(1+2/A3*100,000)
All Accident Frequency Rate
(1+2+3/A3*100,000)

10. Incident History

HEALTH AND
Item 2019 2020 2021 2022 2023
SAFETY
Average Number of
1.1 Employees
Average Number of
1.2 H&S Employees
1.3 Total Man-hours
Number of Work
1.4 Related Fatalities
1.5 Number of LTIs
Number of
Restricted Workday
1.6 Cases (RWC)
Number of Medical
Treatment Cases
1.7 (MTC)
Number of First Aid
1.8 Case (FAC)
Number of Heat
1.9 Stress Related Cases
Property Damage –
Utilities (cables,
1.1 pipelines, etc.)
Property Damage –
Contractor’s Asset
1.11 (barriers,

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HEALTH AND
Item 2019 2020 2021 2022 2023
SAFETY
equipment, tools,
etc.)
Number of
1.12 Significant Incidents
Number of Work-
1.13 Related Illnesses
Number of Non-
Work-Related
1.14 Deaths
Number of Near
1.15 Misses
INJURY
FREQUENCY
2 (Formula = Number
of Cases X 200,000 /
Number of Man-
Hours
Lost Time Injury
Frequency Rate
2.1 (LTIFR)
Total Recordable
Injury Frequency
Rate (TRIR)
Fatality, LTI, RWC &
2.2 MTCs.

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