Information
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Site conducted
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Client / Site
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REPRESENTATIVE RESPONSIBLE FOR HEALTH AND SAFETY:
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POSITION OF REPRESENTATIVE:
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DOCUMENT VERSION CONTROL VERSION:
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DATE:
SECTION 1 - HEALTH AND SAFETY CAPABILITY
Health & Safety Policy & Responsibilities
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Does the Company have a written Health and Safety Policy?
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Evidence
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Is the Health and Safety Policy signed by the Company's Manager/Chief Executive?
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Have management of your organisation attended training to understand their health and safety legal obligations?
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Have Supervisors been formally trained to understand the legal responsibilities they hold on behalf of their Organisation for health and safety?
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Are health & safety responsibilities documented for:
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Management
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Supervisors
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Employees
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Casual Employees
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Are all staff (that will be assigned to work on any Kilwex Ltd site) qualified & competent to carry out their tasks?
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Does your Company have third party certification or approvals (select applicable items)
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Safe T Cert
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C.I.F.
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ISO18001 or ISO45001
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Plant & Equipment
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Does your Organisation have a preventative maintenance program for its plant, machinery and equipment?
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All plant is fitted with safety equipment as per Kilwex Ltd minimum standards e.g. ROPs/FOP's/COP's, seatbelts, quick hitches, etc.
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Plant and equipment is safe to be used for the purpose you intend.
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Your employees who are to operate the plant and equipment are trained in its safe use.
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Your employees have the correct license's and or CSCS cards to operate the plant and equipment.
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Work Methods
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Is your scope of work expected to involve working:
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At Heights
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Image of safe work practice
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Confined Spaces
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Image of Safe Work Practice
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With Hazardous Substances
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Image of Safe Work Practice
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With Mechanical Plant
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Image of safe work practice
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Hot Work (Abrasive Wheel, working with hot bitumen etc.)
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Image of safe work practice
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With Compressed Gases
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Image of safe work practice
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Do you have Safe work practices in place for all of the above that you have responded " yes" to ?
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Is your work expected to involve working around utility services such as:
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Gas
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Image of safe work practice
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Electricity
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Image of safe work practice
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Water
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Image of safe work practice
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Communications
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Image of safe work practice
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Do you have safe work practices in place for all of the above that have you responded "yes" to?
Hazard Management
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Does your Organisation have a process to systematically identify and control significant hazards on site?
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Does your Organisation have a system to record hazards and controls?
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Does your Organisation have a system to advise Kilwex Ltd of any hazards you will bring to the work site?
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Does your Organisation undertake to ensure the safety of the general public in and around your work site?
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Induction and Training
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Does your Organisation have an employee induction program that includes all aspects of Health & Safety?
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Does your Organisation maintain records of personnel when they are inducted?
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Does your Organisation have specific health and safety rules?
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If "yes", are the rules fully explained and understood by all employees?
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Does your Organisation provide and record specific health and safety training for employees?
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Does your Organisation have a documented drug and alcohol policy?
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Have your employees been drug tested in the last 3 months?
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Does your Organisation hold weekly TBT meetings?
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Selection of Subcontractors
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Will your Organisation contract out or involve other personnel besides your own employees in the work you complete for Kilwex Ltd?
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Does your Organisation have a process to determine the health and safety capability of subcontractors?l
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List Subcontractors to be used
Management
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Does your Organisation have:
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An Incident, Dangerous Occurrence and Near Miss reporting/recording system?
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An Incident, Dangerous Occurrence and Near Miss Investigation Process?
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Does your Organisation have a system to report Incidents, Dangerous Occurrence and Near miss to the principal they are working for?
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How many Full Time Employees does your Organisation employ?
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Has your Organisation had any of the following Incidents, Dangerous Occurrence or Near Misses in the last12 months?
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Fatalities
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How Many?
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Serious Harm Accidents
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How Many?
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First Aid Incident
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How Many?
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Near Miss Incidents
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How Many?
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Incidents causing damage to property.
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Has your Organisation ever been prosecuted for a Health/Safety breach?
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Please provide details:
Emergeny Preparedness and Response
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Does your Organisation have emergency response procedures to deal with work site emergencies?
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Will your Organisation have Certified First Aid Responders on site that can respond in the event of an emergency?
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Personal Protective Equipment
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Has your Organisation assessed the jobs/tasks prior to commencement of works?
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Does your Organisation provide/supply PPE & RPE to all staff as required?
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Does the PPE & RPE provided comply with EU Safety Standards?
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Have staff been trained in the correct use of PPE & RPE?
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Health Monitoring
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Does your organisation have a system in place to monitor the health of employees with regard to any hazards the maybe exposed to?
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What is the frequency of your health monitoring Programme? Please select the frequency rate (in years).
References
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Provide two referees that can verify your Company's capability and commitment to your management of HSEQ. Referees may be contacted to verify capability, competency and safe work management.
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Name:
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Company
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Address:
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Telephone:
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Name:
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Company
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Address:
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Telephone:
Insurance Coverage
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Please attach evidence from your Insurance Company/Broker of your current Public Liability, Professional Indemnity and/or Motor Vehicle Insurance cover. Please state any liability limitations for each event.
SECTION 2 - QUALITY MANAGEMENT CAPABILITY
SECTION 2 - QUALITY MANAGEMENT CAPABILITY
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Does your Company maintain an ISO 9000 certified Quality Management System?
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Does your company have a Quality policy or similar document?
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Are you able to provide details of the proposed action plan for implementation?
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Is your company considering ISO 9000 or an alternative structured approach to quality management?
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Are personnel responsible for ensuring the company activities or works comply with Kilwex Ltd requirements nominated and their authority and responsibilities defined?
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Are responsibilities for design control (i.e. who, when, how and review) identified?
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Are procedures for ensuring that current issues of relevant documentation are available at work sites and/or inspections and test points documented?
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Are procedures for purchasing adequately identified, including: sources of materials; procedures for inspection and test of incoming materials for specification compliance; compliance with suppliers recommendations for storage and handling; provision of MSDS and safety information
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Are procedures for evaluation of subcontractor's ability to meet specification requirements and for monitoring quality of subcontract works defined?
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Are procedures documented for identifying all samples and test results with the field locations to which they relate?
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Is there a process control plan for your company's activities that identifies: the process steps; factors affecting quality of products and services; methods used to monitor process; acceptability criteria and verification procedure; all activities where independent inspection, hold points or witness points are required
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Are procedures documented for identification and control of all occasions where the product fails to pass any inspection and test in accordance with defined acceptance criteria?
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Where simple reworking or repair can achieve conformity, are the actions and procedures for notification and recording documented?
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Are procedures for corrective and preventive action documented, including recording and follow-up analysis and improvement?
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Are procedures documented for maintaining quality records?
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Is there a process for ensuring that all personnel have undergone appropriate induction and training to deliver agreed customer requirements?
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Is there a process to review and audit your quality system?
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SECTION 3 - ENVIRONMENTAL MANAGEMENT CAPABILITY
SECTION 3 - ENVIRONMENTAL MANAGEMENT CAPABILITY
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Does your Company maintain an ISO 14001 certified Environmental Management System?
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Is your company considering ISO 14001?
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Are you able to provide details of the proposed action plan for implementation?
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Is your company able to provide a list of environmental consents and permits that are relevant to the company's activities?
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List environmental consents and permits
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Has your company formally assessed the significant environmental aspects of its activities and the associated risks and impacts of these on the environment?
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Does your Company have a documented Environmental System and / or Environmental Plans?
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Does the company have a specific policy or action plan relating to managing waste?
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Does the organisation reuse and recycle waste?
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Does the organisation try to reduce the waste it produces?
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Has your company set targets for environmental improvements, for example, sustainable purchasing, carbon foot print, cleaner production etc?
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Does your company have a specific policy or action plan relating to Transport?
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Does this include:
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1. A system for planning routes?
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2. An effective fuel-management System?
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3. Maintenance schedules for vehicles?
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Has the company set up a programme for training staff on environmental issues?
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Does this include:
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Keeping a record of all employees who receive training?
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Regular updates on environmental issues?
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Within the last three years has your Company:
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Been prosecuted for non compliance with the Resource Management Act, a resource consent or permit?
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Had any infringement, abatement or enforcement notices served on it by an environmental regulator or authority?
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Please give details:
SECTION 4 - COMPANY DETAILS
CONTACT DETAILS:
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COMPANY NAME:
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ADDRESS:
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Phone:
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Fax:
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Email:
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Company Environmental Representative (if different from above)
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Name:
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Position:
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Contact Number:
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Company Health and Safety Representative
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Name:
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Position:
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Contact Number:
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Company Quality Representative (if different from above)
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Name:
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Position:
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Contact Number:
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Company Environmental Representative (if different from above)
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Name:
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Position:
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Contact Number:
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This Capability Assessment has been fully reviewed by a Kilwex Ltd representative and ALL responses have been verified by:
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Signature of Kilwex Ltd Representative
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Signature of Company Representative
