Information
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Client / Site
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REPRESENTATIVE RESPOSIBLE 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
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Is your Company currently part of the ACC WSMP or Partnership Programme (If yes please provide a copy of your current certificate)
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Evidence
Health & Safety Policy & Responsibilities
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Does your 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 your 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 Action Civil 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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QEST
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NZS4801
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Site Safe
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Plant & Equipment
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Does your Organisation have a preventative maintenance programme for its plant, machineryand equipment?
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When using plant and equipment either owned by you, provided to you by Action Civil Ltd or from any other Party (leased, hired, borrowed etc) do you have systems in place to ensure that:
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All plant is fitted with safety equipment as per Action Civil Ltd minimum standards e.g. ROPs/FOP's/COP's, seatbelts, quickhitches 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 licences 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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In Confined Spaces
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Image of Safe Work Practice
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With Chemicals
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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 (welding, 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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Telephone
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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 Action Civil 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 programme that includes health and 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 regular safety (toolbox) 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 Fulton Hogan?
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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
Accident / Incident Management
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Does your Organisation have:Â
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An Accident/Incident reporting/recording system?
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An Accident / Incident Investigation Process?
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Does your Organisation have a system to report incidents/accidents to the principal they are working for?
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How many Full Time Equivalent (FTE ) does your Organisation employ?
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Has your Organisation had any of the following Accidents/Incidents in the last12 months?
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Fatalities  Â
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How Many?
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Serious Harm Accidents
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How Many?
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Medical Treatment Accidents
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How Many?
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Close Call/Near Hit Accidents
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How Many?
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Accidents causing damage during a Contract
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Has your Organisation ever been prosecuted for a health and 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 Aiders on site that can respond in the event of an emergency?
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Personal Protective Clothing and Personal Protective Equipment (PPC & PPE)
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Has your Organisation assessed the jobs/tasks that require PPC/PPE?
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Does your Organisation provide/supply PPC/PPE to all staff as required? Â
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Does the PPC/PPE provided comply with NZ Safety Standards?Â
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Have staff been trained in its correct use?
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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 health and safety. Â 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. Â
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 Fulton Hogan's 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 or the EnviroMark programme?
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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 Fulton Hogan Represtative and ALL responses have been verified by:
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Signature of FH Representative
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Signature of Company Representative
