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CSHP Application Form (Comprehensive)

The document outlines the application process for the Construction Safety and Health Program (CSHP) with no fees required for filing and evaluation. It includes a revised application form that must be completed by contractors or project owners, detailing project information, workforce details, and safety personnel. The application must be submitted with all required documents for processing by the Department of Labor and Employment.

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Dole Qfo
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52 views3 pages

CSHP Application Form (Comprehensive)

The document outlines the application process for the Construction Safety and Health Program (CSHP) with no fees required for filing and evaluation. It includes a revised application form that must be completed by contractors or project owners, detailing project information, workforce details, and safety personnel. The application must be submitted with all required documents for processing by the Department of Labor and Employment.

Uploaded by

Dole Qfo
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
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NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

Revised Form: CSHP Form 1A-2023:


Page 1 of 3
APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. II 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:


Date of Validity:
Male: _____ Female: ____ Total employment:___

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)

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

Complete Project Address/Location:

Name of Project Owner: Tel. No: _______________

Fax No: _______________

Email : _______________

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


be deployed in the project: project:

(Workforce of the project to Month Day Year


Total Project Cost: include workers of the sub-
PhP contractor/s) Duration of the project (Pls. state the number
of calendar days)
Calendar Days
Brief Description of Activities/WorkFlow (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 First Aider:
Name Date of training
Name Date of ID
training Validity

Designated Safety Officers:


Please attach a photocopy of the Certificate of First-Aid
Training and valid First Aid ID from Phil Red Cross, DOH,
(Please attach photocopy of Certificate of Completion on the Bureau of Fire and DOLE- Accredited TVIs with TESDA
Basic OSH Course for Construction Site Safety Officers issued by registered EMS and other DOLE-Accredited first aid
DOLE-BWC accredited Safety Training Organizations or training provider
recognized institution)
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:

(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:
College LEVEL
LARRY D. GO Work Experience in OSH:
Signature over printed name Safety Officer since 2019
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:
Safety Officer

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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