Title Page
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Company/Business Name:
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Evaluation conducted on:
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The Contractor hereby acknowledges that:
1. They understand their obligations to themselves as a Person Conducting a Business or Undertaking, their subcontractors and their workers under the Health and Safety at Work Act 2015 (HSWA), Health and Safety at Work Regulations 2016 and other relevant legislation, Codes of Practice Guidelines / standards, recognised industry good practice and confirm their intention to comply at all times while working on this contract.
2. They recognise that Alaska Construction + Interiors (Alaska) can be responsible for only advising the nature of, and methods of controlling, hazards specific to Alaska’s business or worksite and that the Contractor shall apply recognised industry good practice to ensure the health and safety of all involved at all times.
3. Alaska has advised the Contractor of the emergency procedures, location of emergency equipment, location and use of safety equipment, safety rules, hazards and hazard controls, go and no-go areas and access and authorisation requirements relevant to the service being performed.
4. The Contractor shall ensure that all their employee’s subcontractors and other persons engaged are informed of the same and that no person shall be permitted to work on the contract without being so informed.
5. The Contractor has a Health and Safety management system in place, which ensures their compliance with the HSWA and associated Regulations, other relevant legislation, Codes of Practice Guidelines and recognised industry good practice in connection with this contract.
6. The Contractor agrees to make available for inspection on request by Alaska any documentation related to Health and Safety in connection with this contract.
7. Alaska has the right to monitor the Contractor’s activities and carry out a safety audit from time to time during the progress of the contract.
8. Alaska has the right to suspend work at the Contractor’s expense where Alaska is not satisfied that so far as is reasonably practicable steps are being taken to ensure the Health and Safety of employees and others in connection with the contract.
9. The Contractor will notify Alaska immediately of all accidents that did result or had the potential to result in injury, illness to any person on or in the vicinity of the contracted worksite. The Contractor will notify Alaska immediately of all events that did result or had the potential to result in a Notifiable Incident as prescribed under the HSWA and associated Regulations. The Contractor will notify Alaska immediately of all Notifiable Events as prescribed in the HSWA that occur on the contracted worksite or as a result of the contracted activity.
10. The Contractor will advise Alaska immediately of any new hazard / Risk created during the contract and will take reasonably practicable steps to control the hazard and risk in order to avoid harm being caused to any person as a result of such Risks.
11. Before beginning work on the contract, the Contractor will carry out a thorough systematic Risk Assessment to identify hazards likely to be encountered, assess the risk and develop and implement controls as determined by relevant legislation, codes of practice and recognised good practice guidelines/standards.
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The following questionnaire is designed to help Alaska Construction review your health safety to ensure your organisation has a system & procedures to manage health & safety risks when working under our contract.
Please complete all questions in the survey and be aware that we may conduct site reviews to verify that relevant systems & documentation are in place.
Business Information
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Main type of work
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Main contact person
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Mobile
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Email
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Health & Safety Contact
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H&S Mobile
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H&S Email
Notifiable Works
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Do your works include any particular hazardous work deemed notifiable to WorkSafe?
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Do you agree to notify WorkSafe NZ of any notifiable works at least 24 Hrs prior to the start of the work & provide Alaska with a confirmation?
Safety Policy & Management System
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Do you have a Health & Safety Policy, reviewed and signed by management in the last 12 months?
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Has your Health & Safety Policy been distributed to all workers?
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Has your health & safety system been audited against a recognised standard or prequalification scheme?
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- AS/NZS 4801:2001
- ISO 45001
- ACC Accredited Employers Programme
- Impac Pre-Qual
- Sitewise Contractor Pre-Qualification - Green
- ISNetworld
- Other
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Please specify
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Please email a copy of your Certificate and review to HealthandSafety@alaska.co.nz
Hazard Management
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Do you have a documented Hazard Register and required controls for your works?
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Do you have a documented process to identify and control hazards on a per site basis (e.g. a Task Analysis (TA), Work Method Statement (WMS) or Job Safety Analysis (JSA))?
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Are your Safe Work Procedures & Safety Instructions documented in manuals & reviewed at least annually
Safety Training
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Do your workers all have current health & safety training e.g. Site Safe Passport?
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Do you keep a Training Register of all relevant training & competency for each of your workers?
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Have your workers who undertake specific hazardous work, received formal training in the safe working practices required?
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Are all workers not yet competent in a specific task, specific tool or substance, supervised by someone with relevant experience and competence?
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Are all workers trained to use and supplied with suitable PPE (Personal Protective Equipment) required for specific tasks?
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Are your Supervisors trained in H&S responsibilities and documentation?
Equipment and Heavy Machinery
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Do you use power tools for your works?
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Do you keep a register to ensure all power tools and electrical items are tested and tagged in compliance with AS/NZS 3012?
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Do you require heavy machinery for your works?
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If yes, do you have a maintenance register for all heavy machinery?
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Is your heavy machinery maintained according to manufacturers’ instructions and do you have an effective system in place to identify faults?
Hazardous Substances
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Do you have a Hazardous Substance Register that includes types & quantities of all of your hazardous substances, and copies of all Safety Data Sheets (Hazardous Substance Register)?
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Do you have an Approved Handler for hazardous substances where required (listed in Training Register)?<br>
Safety Records - during last 3 years
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Have you had any safety or environmental notices, improvement notices, warnings or prosecutions from an enforcement agency such WorkSafe NZ, Council, or the Police in the last three years?
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If yes, provide details, penalties, outcome and the corrective actions that you took to improve health and safety standards
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Is your organisation being investigated regarding any incident by an enforcement agency such WorkSafe NZ, Council, or the Police?
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If yes, please provide details
Accident Reporting and Investigation
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Do you have procedures for reporting and investigating incidents?
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Do you keep records of all accidents and near misses?
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Are your workers informed of the outcome of accident investigations and remedial action required
Communication and Safety Awareness
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Hazards introduced by your works will be communicated to Alaska and added to the site hazard board
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Do all your workers understand they need to be inducted to new work sites?
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Do all workers understand to check the hazard board prior to entering any site, every time?
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Do all workers understand they are responsible for keeping themselves and others around them safe?
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Do all workers understand they are to advise the site supervisor of any uncontrolled hazards they encounter on site?
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Do you have worker participation systems (H&S Committee, H&S Representatives, regular safety meetings)
Safety Inspections & Safety Reviews
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Do you conduct regular documented work site safety inspections or reviews<br>
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Are the results of the safety inspections discussed with all workers and the main contractor/principal if required?
Emergencies
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Do you require a documented emergency plan specific to your work?
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Are all workers are made aware of the emergency plan during site induction?
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Do you have a first aid kit and first aid trained personnel to give assistance in the event of an accident (listed in Training Register)?
Contract Workers (Subcontractors)
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Do you employ subcontractors during the course of your works
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Does each of your Subcontractors have their own active H&S Management System?
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Have your Subcontractors competence been formally assessed or reviewed (skills, systems and procedures to work safely on site)?
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Do you have an induction procedure for new Subcontractors?
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Do you have procedures for reviewing the safety performance of Subcontractors e.g. Site Reviews, KPIs?
Documentation Provided
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Accreditation Certificate (AS/NZS4801, ISO45001, IMPAC, SITEWISE etc.)
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Health and Safety Policy
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Safe Work Procedures
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Sample of a JSA or Safe Work Method
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Training Register
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Hazard Register
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Hazardous Substances Register
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Heavy Machinery Maintenance Register
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Public Liability Insurance
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Motor Vehicle Insurance
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Copies of relevant certificates, licences or permits
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Please email a copy of this evaluation and copies of the above ticked documentation to:
HealthandSafety@alaska.co.nz
Declaration
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I am authorised to provide this information and sign this form
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The information provided in this forma is true and accurate description of the health and safety systems to be used by us when contracted to Alaska Construction
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I understand that as a contractor to Alaska Construction I agree to abide by the requirements of the Health and Safety at Work Act 2015 (HSWA) and Amendments, all relevant Codes of Practice issued by WorkSafe NZ, industry standards and other relevant statutes in place at the time
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I have included the required documentation as ticked above
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Contractor Representative:
