Doc. No.

: Re: Project: Client: Project No:

PROJECT DESCRIPTION:

AE. 6.04/Project Supervisor Construction Stage.

Date:
Insert Brief Project Description here.

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1.00. GENERAL
1.01.
Contractor Name:

1.02.

Contractor Address:

1.03. 1.04. 1.05.

No. of Permanent Employees. Is your organisation a member of the C.I.F. ? Yes/No. (Y/N) 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 your insurances in the event of an accident?
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 or not) can be considered suitable grounds for the termination of the contract, by the Client. .

Doc. No.: Re: Project: Client: Project No:

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AE. 6.04/Project Supervisor Construction Stage.

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2.00
2.01 2.02 2.02.1 2.02.2 2.02.3 2.02.4

H&S MANAGEMENT:
Does your organisation have an up to date safety statement.? Y/N. If yes provide copy. Do you have in house Health & Safety expertise? Y/N. If Yes, give Name of individual(s) who will manage safety on this project. Qualification(s) of individual(s) eg I.O.S.H membership, level, duration, etc. Describe the construction safety expertise of the individual(s). 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 manage site safety on this project. Eg qualifications of external safety advisor, construction safety experience of external safety advisor, frequency of site attendance, authority, reporting arrangements, etc. 2.03 2.03.1 2.03.2 Detail your organisations policy with regard to the Health & Safety and Domestic Sub contractors. 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?

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 or not) can be considered suitable grounds for the termination of the contract, by the Client. .

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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.
if No state None.

3.02.1. Improvement Direction: Y/N. If Yes, give details ,ie the number and nature of the incident, etc

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
state None..

if No

3.03.1. Has your organisation been directly prosecuted for breach of any statutory Health & Safety provisions? 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. 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 or not) can be considered suitable grounds for the termination of the contract, by the Client. .

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4.00. H&S TRAINING.

4.01 How many of your full time, site based personnel are trained (certified) Occupational First Aiders? How many of the certified first aiders will be deployed on this project for the duration of this project. 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.) accredited A) Managing Safely in Construction (MSIC) course B) MSIC Renewal Certificate Course

4.02

4.02.1. How many of these trained personnel will be deployed on site, for the duration of this project. 4.03. How many personnel to be deployed on site for this project are FAS trained and certified in the following categories:
Own Personnel Subcontractor Personnel How many deployed on site.

Category Construction Operative Scaffolder-Basic Scaffolder-Advanced Steel Fixer Tractor/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. Item

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

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 or not) can be considered suitable grounds for the termination of the contract, by the Client. .

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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 Project Supervisor 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

______________________________________________

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 or not) can be considered suitable grounds for the termination of the contract, by the Client. .

Doc. No.: Re: Project: Client: Project No:

5.03. 5.04. 5.05.

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Qualifications/Professional Membership Years of safety Experience 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:

______________________________________

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 or not) can be considered suitable grounds for the termination of the contract, by the Client. .