OSH Consultant Accreditation Form
OSH Consultant Accreditation Form
OSH Consultant Accreditation Form
This form is
OSH-C-N
Page 1 of 4
INSTRUCTIONS:
1. Fill in all the data needed.
2. Use BLOCK/PRINTED letters or use a TYPEWRITER.
3. Write N/A if the blanks are Not Applicable.
4. Please sign in all pages of the form.
PERSONAL PROFILE
TITLE
LASTNAME
FIRST NAME
MIDDLENAME
Home Tel.
No.
Mobile No.
E-mail
PRC License
No.
Date of
Birth
Sex
Citizenship
Civil
Status
COMPANY PROFILE
Business Address
Nature of Business
E-mail Address
Region
Website
Fax No.
Zip Code
Employment Size
Male
Female
Total
Type of Service
Workplace
Specific Product
Hazardous
Non-Hazardous
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSH-C-N
Page 2 of 4
DOCUMENTARY REQUIREMENTS
REMARKS
1. Two (2) copies of duly accomplished Application Form (OSHC-N) with 2 copies most recent 1 x 1 ID picture signed at the
back (blue background).
2. Original Certificate of Employment indicating name, position
and date of appointment at present position using the official
letterhead of the company.
3. Original of actual Duties and Responsibilities at present
position, signed by immediate supervisor and Personnel
Manager or authorized official of the company, using
letterhead of the company
4. Photocopy of certificate of employment from previous
employer/s indicating position(s) and date(s) of appointment
(if any and necessary in support of actual experience on
OSH). May submit list of actual functions and proof of
accomplishments, duly certified by the employer.
5. Photocopy of certificate of completion of the DOLE prescribed
advance course (80-hr) on Occupational Safety and Health
issued by accredited STO.
6. Photocopy of certificate of attendance/participation on other
OSH related trainings/seminars/activities.
7. Photocopy of College Diploma or Transcript of Records and
Board Exam Certificate or PRC License (if any).
8. Submission of summarized OSH trainings with a total of at
least 480 hours. Attach photocopy of certificates (Refer to
table below for format)
Table
Title
Issued by
Inclusive Dates
Title/Topic
(From recent to previous)
Time/Duration
No. of
Hours
Conducted
by
Venue
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSH-C-N
Page 3 of 4
Field of Expertise
Brief Description
Years of
Experience
Title
Issued by
Date Issued
Title
Year Taken
Given by
Rating
Designation
Validity
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSH-C-N
Page 4 of 4
Address
Contact No.
E-mail Address
Do you have any pending administrative case? (Yes/No) If YES, please give details.
Do you have any pending criminal case? (Yes/No) If YES, please give details.
Have you ever convicted of any administrative offense?(Yes/No) If YES, please give details.
Have you been convicted of any crime or violation of any law, decree, ordinance or
regulations by any court or tribunal? (Yes/No) If YES, please give details.
Have you ever been retired, forced to resign or dropped from employment in the public
and/or private sector? (Yes/No) If YES, please give reasons.
SIGNATURE
TO BE ACCOMPLISHED IN DUPLICATE
DATE
This form is
OSH-C-R
Page 1 of 4
TITLE
LASTNAME
INSTRUCTIONS:
1. Fill in all the data needed.
2. Use BLOCK/PRINTED letters or use a
TYPEWRITER.
3. Write N/A if the blanks are Not
Applicable.
4. Please sign in all pages of the form.
PERSONAL PROFILE
FIRST NAME
MIDDLENAME
Please attach
your
1 X 1 Picture
2 COPIES
Signed at the
back
Home Tel.
No.
Mobile No.
E-mail
PRC License
No.
Date of
Birth
Sex
Citizenship
Civil
Status
COMPANY PROFILE
Business Address
Nature of Business
E-mail Address
Region
Website
Fax No.
Zip Code
Employment Size
Male
Female
Type of Service
Workplace
Total
Hazardous
Specific Product
TO BE ACCOMPLISHED IN DUPLICATE
This form is
Non-Hazardous
Total Years of
OSH Experience
Company
OSH-C-R
Page 2 of 4
DOCUMENTARY REQUIREMENTS
REMARKS
Two (2) copies of duly accomplished Application Form (OSH-C-R)
with 2 copies most recent 1 x 1 ID picture signed at the back
(blue background).
Summary of Applicants Accomplishments as OSH Consultant
signed by the employer or supervisor using official letterhead of
the company.
Proof/s of accomplishment or participation in OSH:
____ Accident reports
_____ Safety inspection/audit
reports
____ HSC committee report ____ _OSH program prepared/
implemented
____ Other reports prepared by the applicant please specify
______
Photocopy of Certificate of Accreditation (last issued)
Photocopy of other OSH related trainings/seminar attended as
participant after last renewal of accreditation- at least 16 hours
per year or 48 hours of trainings for 3 years, earned from DOLE
recognized/accredited STO/institutions authorized by law.
When There is a Change of Employer/Position:
Original Certificate of Employment indicating name, position
and date of appointment at present position, using official
letterhead of the company.
Original Certificate of actual Duties and Responsibilities at
present position, using official letterhead of the company,
signed by immediate supervisor and Personnel Manager or
authorized official of the company.
INITIAL EVALUATION/REMARKS
Complete documents submitted, signed in all pages
With incomplete documents, for compliance of the above stated
deficiencies with mark X.
For interview on _________ at _____, please call
______________________
Issued by
TO BE ACCOMPLISHED IN DUPLICATE
Inclusive Dates
This form is
OSH-C-R
Page 3 of 4
Title
Issued by
Date Issued
Title
Year Taken
Given by
Rating
TO BE ACCOMPLISHED IN DUPLICATE
This form is
Validity
OSH-C-R
Page 4 of 4
Contact No.
E-mail Address
Do you have any pending administrative case? (Yes/No) If YES, please give details.
Do you have any pending criminal case? (Yes/No) If YES, please give details.
Have you ever convicted of any administrative offense? (Yes/No) If YES, please give details.
Have you been convicted of any crime or violation of any law, decree, ordinance or
regulations by any court or tribunal? (Yes/No) If YES, please give details.
Have you ever been retired, forced to resign or dropped from employment in the public
and/or private sector? (Yes/No) If YES, please give reasons.
I certify that the information stated above are true and correct.
SIGNATURE
DATE
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSHCO-N
Page 1 of 2
INSTRUCTION
Please accomplish completely and attach the required documents. Refer to checklist of
requirements listed below for attachments new and mark in the left portion all documents
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply for an
accreditation as
SAFETY CONSULTING ORGANIZATION
Name of Organization
Company Address
Official Title/Designation
Fax No.
Employment
Size
E-mail Address
Male
Female
Total
Website
CHECKLIST OF REQUIREMENTS
1. Duly accomplished application form.
2. Certified true copy of Business Registration with SEC or DTI
whichever is applicable
3. Certified true copy of Mayors Permit/License to operate.
4. Certified true copy of Registration with DOLE Regional Office.
5. Certified true copy of Registration with BIR.
6. Contract of Agreement with Consultant/Resource Person with valid
accreditation.
7. Resume of Consultants and copy of Certificate of Accreditation.
Received by:
Evaluators Remark
(This COLUMN is
to be
accomplished by
OSHC)
REMARKS
Date/Time:
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSHCO-N
Page 2 of 2
Position
Type of Employment
(Regular, Project
Based, Contractual)
Educational
Background
If contractual
(specify period of
contract)
Technical Use additional sheet if necessary. Please attach resume of technical staff/resource
speakers and contract of agreements with them.
Name of Technical Staff
Highest Educational
Attainment
Field of
expertise/specialization/
competence
If accredited as
OSH Professional,
specify
Accreditation No.
and Validity
REMARKS
J.
K.
L.
M.
N.
Type of OSH Consultancy Please attach list of available equipment necessary in the conduct of
type of OSH consultancy, services, provided. Attach also list of clients (if any)
Type of Services Provided
OSH Safety Program Development and
Fire Prevention, Protection and Control Risk
Implementation
Assessment
OSH Safety Audit/Evaluation
Work Environment Measurement
Occupational Safety Management System
Work Accident Investigation
In-Plant Safety Inspection
Other, Please specify
I certify that the information stated above are true and correct.
SIGNATURE
TO BE ACCOMPLISHED IN DUPLICATE
DATE
This form is
OSH
CO-R
Page 1 of 2
INSTRUCTION
Please accomplish completely and attach the required documents. Refer to checklist of
requirements listed below for attachments new and mark in the left portion all documents
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply of the renewal of
accreditation as
SAFETY CONSULTING ORGANIZATION
Accreditation No.:
Name of Organization
Date of First Accreditation:
Date of Last Renewal:
Company Address
Validity:
Name of Top Company Head
Official Title/Designation
Telephone No.
TIN No.
Fax No.
Employment
Size
E-mail Address
Male
Female
Total
Website
CHECKLIST OF REQUIREMENTS
8. Duly accomplished application form.
9. Certified true copy of Business Registration with SEC or DTI
whichever is applicable.
(This COLUMN is
to be
accomplished by
OSHC)
REMARKS
10.
Certified true copy of Mayors Permit/License to operate.
11.
Certified true copy of Registration with DOLE Regional Office.
12.
Certified true copy of Registration with BIR.
13.
Contract of Agreement with Consultant/Resource Person with
valid accreditation.
14.
Resume of Consultants and copy of Certificate of
Accreditation.
Received by:
Evaluators Remark
(Signature over printed
name)
Position:
Region:
Date/Time:
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSHCOR
Page 2 of 2
Position
Type of Employment
(Regular, Project
Based, Contractual)
Educational
Background
If contractual
(specify period of
contract)
Technical Use additional sheet if necessary. Please attach resume of technical staff/resource
speakers and contract of agreements with them.
Name of Technical Staff
Highest Educational
Attainment
Field of
expertise/specialization/
competence
If accredited as
OSH Professional,
specify
Accreditation No.
and Validity
REMARKS
R.
S.
T.
U.
Type of OSH Consultancy Please attach list of available equipment necessary in the conduct of
type of OSH consultancy, services, provided. Attach also list of clients (if any)
Type of Services Provided
OSH Safety Program Development and
Fire Prevention, Protection and Control Risk
Implementation
Assessment
OSH Safety Audit/Evaluation
Work Environment Measurement
Occupational Safety Management System
Work Accident Investigation
In-Plant Safety Inspection
Other, Please specify
I certify that the information stated above are true and correct.
SIGNATURE
TO BE ACCOMPLISHED IN DUPLICATE
DATE
This form is
OSHSTO-N
Page 1 of 2
INSTRUCTION
Please accomplish completely and attach the required documents. Refer to checklist of
requirements listed below for attachments new and mark in the left portion all documents
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply for an
accreditation as SAFETY TRAINING ORGANIZATION
Name of Organization
Company Address
Official Title/Designation
Fax No.
Employment
Size
E-mail Address
Male
Female
Total
Website
(This COLUMN is to
be accomplished
CHECKLIST OF REQUIREMENTS
15.
Duly accomplished application form.
16.
Certified true copy of Business Registration with SEC or DTI
whichever is applicable
17.
Certified true copy of Mayors Permit/License to operate.
18.
Certified true copy of Registration with DOLE Regional Office.
19.
Certified true copy of Registration with BIR.
20.
Contract of Agreement with Consultant/Resource Person with
valid accreditation
21.
Contract of Agreement with training venue (for applicant
without training venue)
22.
Resume of Consultant/Resource Person and copy of
Certificates of Accreditation and Trainers Training
Received by:
Evaluators Remark
by OSHC)
REMARKS
Date/Time:
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSHSTO-N
Page 2 of 2
Position
Educational
Background
Type of Employment
(Regular, Project
Based, Contractual)
If contractual
(specify period of
contract)
Technical Use additional sheet if necessary. Please attach resume of technical staff/resource
speakers and contract of agreements with them.
Name of Technical Staff
Highest Educational
Attainment
Field of
expertise/specialization/
If accredited as
OSH Professional,
competence
specify
Accreditation No.
and Validity
REMARKS
I certify that the information stated above are true and correct.
SIGNATURE
TO BE ACCOMPLISHED IN DUPLICATE
DATE
This form is
OSH-STOR
Page 1 of 2
INSTRUCTION
Please accomplish completely and attach the required documents. Refer to checklist of
requirements listed below for attachments new and mark in the left portion all documents
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply of the renewal of
accreditation as
SAFETY TRAINING ORGANIZATION
Accreditation No.:
Name of Organization
Date of First Accreditation:
Date of Last Renewal:
Company Address
Validity:
Name of Top Company Head
Official Title/Designation
Telephone No.
Fax No.
TIN No.
Employment
Size
E-mail Address
Male
Female
Total
Website
CHECKLIST OF REQUIREMENTS
23.
Duly accomplished application form.
24.
Certified true copy of Business Registration with SEC or DTI
whichever is applicable
25.
Certified true copy of Mayors Permit/License to operate.
26.
Certified true copy of Registration with DOLE Regional Office.
27.
Certified true copy of Registration with BIR.
28.
Contract of Agreement with Consultant/Resource Person with
valid accreditation.
29.
Resume of Consultant/Resource Person and copy of
Certificate of Accreditation.
Received by:
Evaluators Remark
(This COLUMN is to
be accomplished
by OSHC)
REMARKS
Date/Time:
TO BE ACCOMPLISHED IN DUPLICATE
This form is
OSH-STOR
Page 2 of 2
Position
Educational
Background
Type of Employment
(Regular, Project
Based, Contractual)
If contractual
(specify period of
contract)
Technical Use additional sheet if necessary. Please attach resume of technical staff/resource
speakers and contract of agreements with them.
Name of Technical Staff
Highest Educational
Attainment
Field of
expertise/specialization/
competence
If accredited as
OSH Professional,
specify
Accreditation No.
and Validity
REMARKS
WW.
Office is located in suitable location having a business-like environment accessible
to means of public transportation and with proper identification.
XX. Has at least 3 office tables and chairs.
YY. Office has sufficient space to move around comfortably. With at least 25 sq. Meter.
ZZ. Lighting and ventilations are adequate.
AAA.
Has at least one set of each of the following items: Telephone, fax machine and
other suitable communication equipment.
BBB.
Has at least one set of working computer and printer.
CCC.
Has one regular staff available to answer telephone calls and queries during office
hours.
DDD. Has a person authorized to issue company decisions.
EEE.
Receiving area has at least 1 table and chairs for staff & clients.
FFF.Meeting or briefing room can accommodate at least 6 persons.
GGG. Files and equipment are properly stored, labelled and well secured.
HHH. There is suitable storage area/place for equipment and records.
III. Has at least one regular subscription to safety and health related materials.
JJJ. Maintains an updated library of safety and health materials, books, standards and
related materials.
KKK.
Has equipment/materials necessary for the type of OSH trainings provided (e.g.
LCD projector, laptop/computer, sample PPE).
LLL.
Has clean and sanitized comfort room.
I certify that the information stated above are true and correct.
SIGNATURE
DATE
DOLE OSHC-STO-Tr
Approved by:
Training Organization:
Address:
May we request for the approval on the conduct of OSH Training specified below.
Title of Training and Specific Topic
( ) new venue
New Schedule/Date of
Training
( ) new/additional speakers