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CSHP Form 1A-2023 Application-Form

The document announces that there are no fees required for filing and evaluating applications for Construction Safety and Health Programs (CSHPs). It provides the application form for contractors to submit to obtain approval for a CSHP for a specific construction project. The multi-page form requires applicants to provide details about the contractor, project, assigned safety personnel, equipment to be used, and the person who prepared the CSHP. Submission of a complete application with all required documents and attachments will be processed for evaluation and approval.

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5K views

CSHP Form 1A-2023 Application-Form

The document announces that there are no fees required for filing and evaluating applications for Construction Safety and Health Programs (CSHPs). It provides the application form for contractors to submit to obtain approval for a CSHP for a specific construction project. The multi-page form requires applicants to provide details about the contractor, project, assigned safety personnel, equipment to be used, and the person who prepared the CSHP. Submission of a complete application with all required documents and attachments will be processed for evaluation and approval.

Uploaded by

depusoyjazzy0217
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

Revised Form: CSHP Form 1A-2023:


Date of Revision: 30 April 2023 Page 1 of 3
APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ________ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Legal Bases: Type of Construction Project:
1. Presidential Decree No. 442, as renumbered _____DPWH project
2. Republic Act No. 11058 _____Other Public/private construction project
3. Department Order No. 198, Series of 2018
(LGUs, other gov’t offices, private entities)
_____ Residential project engaging the services of
a construction firm
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR/SUBCONTRACTOR/BUILDING OWNER in applying for a Construction Safety and Health Program
intended for a specific construction project.

Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with
complete requirements and attachments will be processed.

A. Company Profile/License/Registration of Main/General Contractor


Complete Name of the Company/Main/ Complete Address of the Project
General Contractor/Project Owner

Tel. No: __________________________________________________


Fax No. ___________________________________________________

Name of Project Manager/Owner/ Tel. No: ___________________________________________________


Contact Person: Email: _____________________________________________________

Contractor’s PCAB/JV License No: Number of workers:


________________________________
Male: _____ Female: _____ Total employment: _____
Date of Validity:___________________
Engaged Subcontractors’ Profile

Name of Sub-contractors Scope of Work and No. of Workers PCAB Date of Date of DOLE
(If any) Project Cost License Validity Registration

1.

2.

3.

4.

5.

6.

7.

(Use separate sheet, if necessary)


APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ________ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

B. Project Profile/Description
Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or other documents indicating
name and details of the project)

Complete Project Address/Location:

Name of Project Owner: Tel. No: _____________

Fax No: _____________

Email : _____________

Project Classification: Estimated No. of Workers to be Date of Estimated Start/Execution of the


deployed in the project: project:

___________________ ________/________/_________
Month Day Year
(Workforce of the project to
Total Project include workers of the sub- Duration of the project (Pls. state the number
Cost:__________________ contractor/s) of calendar days)
___________________________
Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary)

Revised Form: CSHP Form 1A-2023 Page 2 of 3


Date of Revision: 30 April 2023
APPLICATION FORM
Department of labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ______ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
OSH Personnel assigned to the project
Designated Safety Officers: Designated First Aider:

Name Date of Name Date of ID


training training Validity

(Please attach photocopy of Certificate of Completion on the Basic Please attach a photocopy of the Certificate of First-Aid
OSH Course for Construction Site Safety Officers issued by DOLE- Training and valid First Aid ID from Phil Red Cross, DOH,
BWC accredited Safety Training Organizations or recognized Bureau of Fire and DOLE- Accredited TVIs with TESDA
institution) registered EMS and other DOLE-Accredited first aid training
provider
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of required BOSH Training
OH Nurse
OH Physician
Dentist
(If Heavy Equipment will be used in the Project)
List of heavy equipment to be used in the Project: Name of Heavy Equipment Operator/s:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
(Please attach additional sheet, if necessary.) (Attach photocopy of skills certification from TESDA.)
Profile of the person who prepared the CSH Program for the abovementioned Project
Educational Background:

Work Experience in OSH:


___________________________
Signature over printed name Other Qualifications:

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULNESS OF THE ABOVEMENTIONED INFORMATION. THE


COMPANY HEREBY COMMITS TO STRICTLY IMPLEMENT THE ATTACHED CONSTRUCTION SAFETY AND
HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.

Submitted By:

Signature Over Printed Name of the Position Date


Owner/Contractor
Assigned Evaluator
I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON
THE DOLE PRESCRIBED CHECKLIST.
Evaluated By:

Signature Over Printed Name Position Date

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