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Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
SafetyAssessmentSchemeQuestionnaire(V19–20/02/17)AssessmentRequired
Contractor Consultant PrincipalContractors PrincipalDesigner
Non-Construction Designer Group–PleasecontactusforinformationandpricingWorkUndertaken:
CompanyName:
StreetAddress:
City:
County:
Postcode:
PhoneNumber:
Nameofprimarycontactwithinthecompany: EmailAddress:
NumberofStaff:
Employees:LabourOnlySubcontractors:Sub-ContractCompanies:
TradeMemberships: Pleasesubmitcopiesofrelevantmemberships: Contractors,ConsultantsandNon-ConstructiontocompletesectionAPrincipalContractorstocompletesectionsA&BDesignerstocompletesectionsA&CPrincipalDesignertocompletesectionsA,C&D
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
SectionA-(Tobecompletedbyall)Question1–HealthandSafetyPolicy–StatementofIntentPleaseTickPleasesubmitasignedcopyofthecompany’sStatementofIntent:
Statementofintentsignedby:
Positionwithinthecompany:
Dateoflastreview
Or
Thecompanyhavelessthan5employeesanddoesnothaveawrittenStatementofIntent.
Question2–HealthandSafetyPolicyDocumentPleaseTickPleasesubmitacopyofthecompleteH&SPolicy(Inc.ResponsibilitiesandArrangements).
Thecompanyhavelessthan5employeesanddoesnothaveawrittenH&SPolicy.
Question3–Reviews,MonitoringandAudits PleaseTickPleasesubmitcopiesofformalH&Sreviews,auditsand/orsiteinspectionsetc.
Pleasesubmitmanagementactionstakeninresponsetositeinspectionsand/orauditsetc.
OrThecompanyhaslessthan5employeesandworksunderlargePCs/Clientsonalloccasions,proceduresareregularlyassessedandnon-conformances/recommendationsareactioned.
Question4–ContractAssessment,MonitoringandReviewing.PleaseTickDoesthecompanyuselabouronlysub-contractors? Y/N
Ifyes,pleasesubmitacompletedcopyofaquestionnaireusedandtheprocedurefollowedtoassessandmonitorlabouronlysub-contractors. Doesthecompanyusesub-contractorcompanies? Y/N
Ifyes,pleasesubmitacompletedcopyofthequestionnaireusedandtheprocedurefollowedtoassessandmonitorsub-contractcompanies.
Question5–ConstructionPhaseHealth&SafetyPlan
UndertheCDMRegulations2015ifyouareworkingasamaincontractororaretheonlycontractorappointedonanycommercial/domesticprojectyouarelegallyrequiredtoproduceaConstructionPhaseHealth&SafetyPlan.www.hse.gov.uk/pubns/cis80.pdf PleaseTick
PleasesubmitarecentexampleofaConstructionPhaseHealth&SafetyPlan.OrWedonotperformeitheroftheabovestatedroles.
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
Question6–MethodStatements,RiskandCoSHHAssessmentsPleaseTickPleasesubmittwocopiesofsitespecificmethodstatementsfromtheprevious12months.
PleasesubmittwocopiesofsitespecificRiskAssessmentfromtheprevious12months.
PleasesubmittwocopiesofCoSHHAssessmentsfromtheprevious12months.
Orthecompanydoesnotuseanyhazardoussubstances.
Question7–TrainingQualificationsforChiefExecutives,Directors,ProprietorsandPartners PleaseTickPleasesubmitcopiesoftrainingcertificates/cardsandcompletethetablebelow.
Name
Position
Trad
eQua
lifications
NEB
OSH
CITB
/IO
SHDirectin
gSafely
FirstA
idTraining
SMSTS
SSSTS
CSCS/CPC
S/CIRS
RS
AsbestosTraining
OtherH&STraining
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
Question8–TrainingQualificationsforManagers,SupervisorsandForemen. PleaseTickPleasesubmitcopiesoftrainingcertificates/cardsandcompletethetablebelow.
Name
Position
Trad
eQua
lifications
NEB
OSH
IOSH
Man
agingSafely
FirstA
idTraining
SMSTS
SSSTS
CSCS/CPC
S/CIRS
RS
AsbestosTraining
OtherH&STraining
Question9–TrainingQualificationsforEmployees. PleaseTickPleasesubmitcopiesoftrainingmatrixand/ortrainingplans.
Pleasesubmitcopiesoftrainingcertificates/cardsandcompletethetablebelow
Name
Position
Trad
eQua
lifications
IOSH
WorkingSafely
FirstA
idTraining
SMSTS
SSSTS
Health&SafetyAwaren
ess
CSCS/CPC
S/CIRS
RS
AsbestosTraining
OtherH&STraining
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
Question10–EnforcementAction PleaseTickHasthecompanyhadanyenforcementactionstakenagainstitintheprevious5years? Y/N
Ifyes,pleasesubmitcopiesoftheenforcementactiontakenandmanagementresponses.
Question11–Accidents/Incidents(RIDDOR) PleaseTickPleasesubmitcopiesofaccidentandnearmissreportingprocedures.
Pleasesubmitcopiesofaccidentstatistics.(Statisticsofallaccidentsmustbeprovided).
HasthecompanyhadanyRIDDORreportableaccidentsorincidentswithintheprevious3years? Y/N
Ifyes,pleasesubmitcopiesofRIDDORreportableaccidents/incidentsandmanagementresponses.
Question12–WelfareFacilities PleaseTickPleasesubmitcopiesofcompletedSiteWelfareChecklistsand/orproceduresregardingsite
facilities.ThismaybeevidencedwithinyourmethodstatementsorH&SPolicy.
Question13a–ConsultationandCommunication PleaseTickIsthecompanysmall(lessthan5people)&communicationverbal? Y/N
Ifno,pleasecompleteatleastoneofthefollowing:
PleasesubmitcopiesofMethodStatementswithcompletedsignatureblocks.
PleasesubmitcopiesofSafetyMeetingMinutes.
Or-PleasesubmitcopiesofcompletedToolboxTalks.
Question13b–ExternalCommunication(Co-operation&co-ordinationwithotherorganisations?) PleaseTickIsthecompanysmall(lessthan5people)&communicationverbal? Y/N
Ifno,pleasecompleteatleastoneofthefollowing:
Pleasesubmitcopiesofthecompany’scommunicationprocedures.
PleasesubmitcopiesofSafetyMeetingMinutes.
Pleasesubmitcopiesofsafetymessages/briefings.
Otherdocumentsasspecifiedhavebeensubmitted.
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
Question14–HealthandSafetyAdvicePersoninternallyresponsibleforH&S. HowdoestheinternallyresponsiblepersonkeepabreastofH&Slegislation/updates?
Whatqualificationsdoestheinternallyresponsiblepersonhave?
PleaseTick
Pleasesubmitcopiesoftheabovementionedqualifications.
DoesthecompanyuseanexternalconsultancycompanytoassistwithHealthandSafetymatters? Y/N
Nameoforganisation.
PhoneNumber/Website.
E-mailAddress.
Pleasesubmitacopyofthecompany’scontractwiththeH&SConsultant,ifapplicable.
Pleasesubmitcopiesoftheconsultant’squalifications/C.V.
Question15–AppropriateInsurances LevelInsured ValidUntil
EmployersLiability
PublicLiability
ProfessionalIndemnity(PI)
ContractorsAllRiskInsurance(PCOnly)
PleasesubmitcopiesofInsuranceCertificatesandSchedules.
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
SectionB-(PrincipalContractorsOnly)
Question16–Principal/MainContractor DoesthecompanyundertaketheroleofPrincipleContractor? Y/N
Ifyes,pleasesubmitacompletedcopyofaConstructionPhaseH&Splan(CPHSP)usedwithinthelast12months.PleaseseethebelowlistoftopicsthatshouldbecoveredwithinyourCPHSP:
• Descriptionofproject.• Detailsofkeymembersoftheprojectteamalongwithkeydates.• Health&safetyaimsfortheproject.• Siterules.• Arrangementstoensurecooperationbetweenprojectteammembers&coordinationof
theirwork,e.g.regularsitemeetings.• Arrangementsforinvolvingworkers.• Arrangementsformonitoring&reviewingyourH&Smanagementsystems• Siteinduction.• Welfarefacilities.• Sitesecurity• Selectionofcompetentcontractors.• Fire&emergencyprocedures.
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
SectionC-(DesignersOnly)
Question17–Competence PleaseTick
Pleaseprovideevidenceofhowthecompanyensuresthatappropriatecapabilities(knowledge/experience)areinplace;enablingthedischargingoflegaldutiesunderhealthandsafetylegislatione.g.qualifications,trainingplansandC.V’setc.
Question18–Co-ordinationandco-operation PleaseTickPleaseproviderecentevidencedetailinghowthecompanyensuresco-operationandco-ordination
ofdesignworkwithinthedesignteamwithotherdesigners/contractors.
Question19–DesignRiskmanagement PleaseTickPleaseproviderecentevidencedetailinghowthecompanyensureshazardsareeliminatedand
showhowremainingrisksaremanaged,(withreferencetobuildability,maintainabilityanduse).
Question20–Workplacestructures PleaseTick
PleaseproviderecentevidencedetailinghowthecompanyensuresthatanystructurethatwillbeusedasaworkplacewillmeetrelevantrequirementsoftheWorkplace(Health,SafetyandWelfare)Regulations1992.
Question21–Designchange PleaseTickPleaseproviderecentevidenceoralternativelyawrittenprocedureexplaininghowthecompany
hasorwillmanagedesignchangeandliaisewithothers.
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
SectionD-(PrincipalDesigner)
Question22–H&SAdvice&assistance PleaseTick
PleaseprovideevidenceofwhoprovidesthecompanywithconstructionrelatedH&Sadvice,thisindividualmaybedirectemployeeoranexternalconsultant.Isthisthesameindividual/companyasQ14? Y/N
Question23–Competence&Qualifications. PleaseTickPleasesubmitevidenceoftrainingandexperienceenablingthePrincipalDesignerstofulfiltherole.
Pleaseprovidecopiesoftrainingcertificates/membershipcards.
Name
Position
CIAT
CIBS
E
CIOB
ICE
IET
RICS
RIBA
ICE
IMechE
IStructE
Question24–Co-ordination&Communication PleaseTick
Pleaseproviderecentworkedexamplesdetailinghowyoucoordinatedesignersandoverseedesigndecisionse.g.writteninstructions,minutesofmeetingsetc.PleaseproviderecentexamplesshowinghowyoucommunicatewiththePrincipalContractor.
Question25–NotifyingtheClient PleaseTick
Pleaseprovideworkedexamples/procedurestoensurethatyoumakeClientsareawareoftheirdutiesundertheCDMRegulations2015.AdditionallypleaseproviderecentevidencedemonstratinghowyouassisttheclientintheprovisionofthePre-Constructioninformatione.g.Asbestossurvey,contaminatedlandandstorageofhazardoussubstancesetc.
Question26–Health&SafetyFile PleaseTick
PleaseproviderecentworkedexamplesofH&SfileswhichhavebeenprovidedtoClientsonthecompletionofprojects.
Bergstrand House Parkwood Close
Roborough Plymouth
PL6 7SG
[email protected] www.greenlightsc.co.uk
01752 604713
Nameofpersoncompletingapplication
Rolewithinthecompany
MobileNumber
Signature
Dateofcompletion
