8/2/2019 CONH&S-CV

1/6

Doc. No.: AE. 6.04/-Re: Project Supervisor Construction Stage.Project:Client:Project No: Date: Page No. 1 of 6

Important Note:

The Health & Safety experience and qualifications of contractors tendering for the project will be considered as a factor in

determining the awarding of this contract. Full disclosure of all information is required and should this contractor fail to disclose

any fact or matter relevant to Health & Safety and this subsequently comes to light, this failure to disclose (whether deliberate ornot) can be considered suitable grounds for the termination of the contract, by the Client.

.

PROJECT

DESCRIPTION:

Insert Brief Project Description here.

1.00. GENERAL

1.01. Contractor Name:

1.02. Contractor Address:

1.03. No. of Permanent Employees.

1.04. Is your organisation a member of the C.I.F. ? Yes/No. (Y/N)

1.05. Do you have Employer Liability Insurance?: Y/N. Give Details. (Broker, expiry date, amount,etc.)

1.06. Do you have Public Liability insurance?: Y/N. Give details. (Broker, expiry date, amount,etc.)

1.07. Do you have Contractors All Risks insurance?: Y/N. Give details. (Broker, expiry date,amount, etc.)

1.07.Do any of your insurers impose Endorsements, terms &/or conditions which will restrict yourinsurances in the event of an accident?

8/2/2019 CONH&S-CV

2/6

Doc. No.: AE. 6.04/-Re: Project Supervisor Construction Stage.Project:Client:Project No: Date: Page No. 2 of 6

Important Note:

The Health & Safety experience and qualifications of contractors tendering for the project will be considered as a factor in

determining the awarding of this contract. Full disclosure of all information is required and should this contractor fail to disclose

any fact or matter relevant to Health & Safety and this subsequently comes to light, this failure to disclose (whether deliberate ornot) can be considered suitable grounds for the termination of the contract, by the Client.

.

1.08.

2.00 H&S MANAGEMENT:

2.01 Does your organisation have an up to date safety statement.? Y/N. If yes provide copy.

2.02 Do you have in house Health & Safety expertise? Y/N. If Yes, give

2.02.1 Name of individual(s) who will manage safety on this project.

2.02.2 Qualification(s) of individual(s) eg I.O.S.H membership, level, duration, etc.

2.02.3 Describe the construction safety expertise of the individual(s).

2.02.4 Give details of your site safety management structure.2.02.5. Outline the resources available to your H&S management team with regard to support

facilities, OSH related Information Databases, etc.

If you answered No to question 2.1. please give exact details as to how you propose to managesite safety on this project.Eg qualifications of external safety advisor, construction safety experience of external safetyadvisor, frequency of site attendance, authority, reporting arrangements, etc.

2.03 Detail your organisations policy with regard to the Health & Safety and2.03.1 Domestic Sub contractors.2.03.2 Nominated Sub Contractors.2.03.3. Describe briefly how you vet sub contractors with regard to Health & Safety.

3.00 H&S STATISTICS & PROSECUTIONS.

3.01 Please provide the following information with regard to all sites where you were carrying

out the duties of PSCS.2012 2011 2010 2009

How many S.39 Ex Parte High Court Orders have

you received.?

How many Prohibition Notices have you

received.?

How many Improvement Notices have you

received?

How many improvement Directions have you

received?

8/2/2019 CONH&S-CV

3/6

Doc. No.: AE. 6.04/-Re: Project Supervisor Construction Stage.Project:Client:Project No: Date: Page No. 3 of 6

Important Note:

The Health & Safety experience and qualifications of contractors tendering for the project will be considered as a factor in

determining the awarding of this contract. Full disclosure of all information is required and should this contractor fail to disclose

any fact or matter relevant to Health & Safety and this subsequently comes to light, this failure to disclose (whether deliberate ornot) can be considered suitable grounds for the termination of the contract, by the Client.

.

How many reportable accidents occurred on your

sites?

How many man days were lost as a result of these

accidents,

How many reportable incidents occurred on sites

3.01.1. Do you have a system to investigate accidents? Yes/No. If yes briefly describe same.3.01.2. Have all your supervisors been instructed on accident reporting/investigation procedures?

Yes/No.

3.02. Please give details on the following for the last 3 years starting with 2000.

3.02.1. Improvement Direction: Y/N. If Yes, give details ,ie the number and nature of the incident, etc if No state None.

3.02.2. Improvement Notice: Y/N. If Yes, give details ,ie the number and nature of the incident, etc if No state None..

3.02.3. Prohibition Notice: Y/N. If Yes, give details ,ie the number and nature of the incident, etc if No state None..

3.02.4. S.39 Ex parte High Court Order: Y/N. If Yes, give details ,ie the number and nature of the incident, etc if Nostate None..

3.03.1. Has your organisation been directly prosecuted for breach of any statutory Health & Safetyprovisions? Y/N?If No state None, If yes give details, etc.

3.03.2. Are there any H&S related prosecutions directly pending against your organisation. Y/N?If No state None, If yes give details, etc.

8/2/2019 CONH&S-CV

4/6

Doc. No.: AE. 6.04/-Re: Project Supervisor Construction Stage.Project:Client:Project No: Date: Page No. 4 of 6

Important Note:

The Health & Safety experience and qualifications of contractors tendering for the project will be considered as a factor in

determining the awarding of this contract. Full disclosure of all information is required and should this contractor fail to disclose

any fact or matter relevant to Health & Safety and this subsequently comes to light, this failure to disclose (whether deliberate ornot) can be considered suitable grounds for the termination of the contract, by the Client.

.

4.00. H&S TRAINING.

4.01 How many of your full time, site based personnel are trained (certified) Occupational FirstAiders?How many of the certified first aiders will be deployed on this project forthe duration of this project.

4.02 How many of your full time, site based staff have successfully completed the C.I.F. run,Institute of Occupational Safety & Health (I.O.S.H.) accreditedA) Managing Safely in Construction (MSIC) courseB) MSIC Renewal Certificate Course

4.02.1. How many of these trained personnel will be deployed on site, for the duration ofthis project.

4.03. How many personnel to be deployed on site for this project are FAS trained and certified inthe following categories:

Category Own Personnel Subcontractor Personnel How many deployedon site.

Construction Operative

Scaffolder-Basic

Scaffolder-Advanced

Steel FixerTractor/Dozer operator

Built up/Roofer Felter

Slinger/Signaller

Roofer Sheeter/Wall Cladder

Tower Crane Operator.

Telescopic Handler

360o Excavator Operator.

180o Excavator Operator.

4.04. Do you have a Safety Training Program for Workers? Yes/No.Item Description G.O`s. Supervisory

8/2/2019 CONH&S-CV

5/6

Doc. No.: AE. 6.04/-Re: Project Supervisor Construction Stage.Project:Client:Project No: Date: Page No. 5 of 6

Important Note:

The Health & Safety experience and qualifications of contractors tendering for the project will be considered as a factor in

determining the awarding of this contract. Full disclosure of all information is required and should this contractor fail to disclose

any fact or matter relevant to Health & Safety and this subsequently comes to light, this failure to disclose (whether deliberate ornot) can be considered suitable grounds for the termination of the contract, by the Client.

.

4.04.1. Does this include Sub Contractors Nominated &/or Domestic? Yes/No.

5.00. REFERENCES & PSCS EXPERIENCE.

5.01. Give details of the last 4 projects on which you carried out the duties of the ProjectSupervisor for the Construction stage.

Project Description:

Referee:

Time Frame:

Value of contract:

Project Description:

Referee:

Time Frame:Value of contract:

Project Description:

Referee:

Time Frame:

Value of contract:

Project Description:

Referee:

Time Frame:

Value of contract:

Information included under the heading Referee shall include the name of the Project Architect, The name of the

Architectural Practise and a contact phone number.

5.02. Who will be carrying out the role of PSCS ______________________________________________

8/2/2019 CONH&S-CV

6/6

Doc. No.: AE. 6.04/-Re: Project Supervisor Construction Stage.Project:Client:Project No: Date: Page No. 6 of 6

Important Note:

The Health & Safety experience and qualifications of contractors tendering for the project will be considered as a factor in

determining the awarding of this contract. Full disclosure of all information is required and should this contractor fail to disclose

any fact or matter relevant to Health & Safety and this subsequently comes to light, this failure to disclose (whether deliberate ornot) can be considered suitable grounds for the termination of the contract, by the Client.

.

5.03. Qualifications/Professional Membership ______________________________________________5.04. Years of safety Experience5.05. Years of Construction Experience

DECLARATION:

I confirm that the information provided in this document is accurate to the best of my knowledge.

Furthermore I understand that it will be used in determining competence to carry out the duties of

Project Supervisor Construction Stage, as set down in the 2005 Construction Regulations. Therefore,

while I understand the information provided will be treated in a confidential manner, I confirm that

I have no objection to this information being divulged to the client (and/or his/her H&S or other

professional Advisor) as part of this assessment procedure.

Signed: ______________________________________

For The Contractor.

Position: _______________________________________

Date: ______________________________________