Scribd
Upload
150 views3 pages

Questionnaire

This document is a contractor safety, health and environment assurance questionnaire from Burtons. It requests information from contractors including: copies of their health and safety and environmental policies; details on their safety management system and arrangements; licenses and trade accreditations; insurance certificates; accident statistics; and a signature confirming accurate completion. The questionnaire will be reviewed by Burtons and the contractor to agree on safety arrangements appropriate for the contractor's work.

Uploaded by

Jamesss Black
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
150 views3 pages

Questionnaire

This document is a contractor safety, health and environment assurance questionnaire from Burtons. It requests information from contractors including: copies of their health and safety and environmental policies; details on their safety management system and arrangements; licenses and trade accreditations; insurance certificates; accident statistics; and a signature confirming accurate completion. The questionnaire will be reviewed by Burtons and the contractor to agree on safety arrangements appropriate for the contractor's work.

Uploaded by

Jamesss Black
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Reference HSMS 3.

37
Issue no. 2
Date Dec 2013
Author D Bowles
Approved D Miles
CONTRACTOR SAFETY, HEALTH AND ENVIRONMENT
ASSURANCE QUESTIONNAIRE
Contractor Company Name:
Burtons Contact:
Guideline for completion:
 You are requested to complete this questionnaire to the best of your ability.
 The answers will be used as the basis for a review with your Burtons’ site contact, during which you will agree a way
ahead in building your safety arrangements to the level appropriate to the type of work that you perform for Burtons.
 Not being able to answer ‘yes’ to a question is not a bar to working with Burtons. For smaller contractors especially,
some requirements may be non-applicable – this will be decided by Burtons in consultation with you.
 There is no requirement to produce any paper evidence at this stage, other than where specifically indicated. After
review, you may be asked to provide specific arrangements or records.
 Where possible, please provide electronic copies of certificates, policies and supporting evidence.
QUESTION Notes on Answers
POLICY
Provide a copy of your health and safety policy Provide Copy
statement
Provide a copy of your environmental statement. Provide Copy
Please state who has signed these. Name:
Position:
ORGANISATION
Indicate whether you utilise a health and safety Name:
professional. Position:
Please provide details of their qualifications. Qualification:
ARRANGEMENTS Yes/No Comments
Do you have a formal health and safety System?
Is the system accredited to a recognised standard? If yes, please state standard:
Does the safety management system include formal
arrangements covering:
- Accident reporting and investigation
- Incident reporting and investigation
- Risk assessments which have identified the key risks
associated with your work activities
- A safety inspection of work areas at contractors’
premises.
- Safety inspections of contract work areas at clients
premises
- The planned inspection and maintenance of specific
equipment
- The use of personal protective equipment for
specified tasks
- Discipline for safety compliance issues
- Consultation with employees
- Safety briefings to all employees
- Training for managers/supervisors in critical aspects of
safety management appropriate to the company’s
activities
- Training for employees in critical aspects of safety
appropriate to the risks they face and pose to others.

THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED


Reference HSMS 3.37
Issue no. 2
Date Dec 2013
Author D Bowles
Approved D Miles
CONTRACTOR SAFETY, HEALTH AND ENVIRONMENT
ASSURANCE QUESTIONNAIRE
- Established written rules and practices for critical
tasks.
- A permit to work system
- Assessing job specific risk and writing accurate
method statements
- Emergencies, first aid etc.
- Vetting of sub-contractors
- Internal auditing of the management system
- External auditing of the management system
LICENSING Yes/No
Does any aspect of your work have to be licensed by a Provide
local authority or other licensing body? licenses/authorisations:
FOOD SAFETY Yes/No
Have any of your employees attended any food safety Provide copies of any certificates
training courses?
TRADE ACCREDITATION/PROFESSIONAL BODIES Yes/No
Are you a member of any trade body, which provides Name:
any type of active accreditation/audit/monitoring?
If yes, please state.
EXPERIENCE
What experience do you have in the type of work you
propose to do/are doing?
INSURANCE
Please enclose copies of your public/third party liability Provide copies.
and employer’s liability insurance certificates.
ENVIRONMENT Yes/No Comments
Do you have any formal Environmental Management
System?
Have you had any environmental incidents over the last
5 years?
If so, please provide brief description.
Do you intent to be transporting your waste from site?
If so, please provide a copy of your waste carrier’s
license.
ACCIDENT DATA
Provide accident statistics below Provide details for current year and 3 years previous
Year Number of Number of over 3 Number of HSE Number of HSE Reportable Injury
Employees day injuries ‘Major Injuries’ Fatalities Rate/100,000 Hours*

*Reportable Rate = No of HSE reportable injuries/number of hours worked * 100,000

This document has been completed to the best of my knowledge.

Completed By:

THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED


Reference HSMS 3.37
Issue no. 2
Date Dec 2013
Author D Bowles
Approved D Miles
CONTRACTOR SAFETY, HEALTH AND ENVIRONMENT
ASSURANCE QUESTIONNAIRE
Position:
Date:

THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED

You might also like