Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Pre-qualification Process
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Name of Applicant/Company
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Name of person completing this application
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Contact information
Phone:
Email:
Web Address: -
PO Box address: Physical address:
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Select date
Health and safety system (Question 1)
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Do you use a safety system/manual containing safety procedures and rules? <br>If yes, please tell us what that is?<br><br>Help guide: The safety system concept calls for a risk management strategy based on identification, analysis of hazards and application of remedial controls using a systems-based approach. As a business, do you have a system to manage your business operations
Competent person (Question 2)
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Do you have access to a competent person for health and safety advice? <br><br>Select yes if they meet the following criteria:<br><br>Examples:<br>Are they a member of a professional association? <br>Can they provide evidence of relevant training and knowledge, such as formal qualifications? <br>Do they have practical experience in your industry or type of business activity? <br>Are they happy for you to contact their clients about the work they have done for them? <br><br>Help guide: As an employer, you must appoint someone competent to help you meet your health and safety duties. A competent person is someone with the necessary skills, knowledge and experience to manage health and safety. <br><br>
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Health & Safety Policy (Question 3)
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Do you have a current copy of your Health & Safety Policy (not older than 2 years)<br><br>If yes, please upload a current copy<br>
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Safety management systems (Question 4)
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Does your company hold any recognized health and safety management systems accreditation or ACC program accreditation? <br><br>If yes, please upload your certificate.<br><br>Help Guide: Certification may include ACC’s Work Safety Discount (WSD), Workplace Safety Management Practises (WSMP) or other third-party accreditation audited to 4801 or 18001 for example.<br>
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Site specific safety plan (Question 5)
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Do you use a Site-specific safety plan (SSSP) pre-works?<br><br>Help guide: The (SSSP) is an agreement between businesses working on a specific site that determines how health and safety will be managed. For more information visit. https://www.sitesafe.org.nz/products-and-services/sssp/<br>
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Affiliations (Question 6)
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Is your company a member or affiliate of any trade or professional organisation? <br><br>If yes please upload relevant certificates.<br><br>Help guide: This may include recognised membership for any professionally recognised organisation. <br>http://www.indexnz.com/Top/Business-and-Economy/Services/Professional-Associations<br>
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Incident Managment (Question 7)
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Please state the arrangements in place for reviewing your health and safety systems.<br> <br>e.g. internal/external audits, safety tours, inspections, management reviews<br>Help guide: We are looking for evidence of the type of system you use to record and communicate all relevant matters relating to health and safety, this may be an integrated electronic system or a paper based process.
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Hazardous Substances (Question 8)
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In relation to potentially hazardous products, materials and substances, do you maintain a Hazardous Substances Register/products register or inventory?<br> <br>For those businesses that manage hazardous substances, From 1 December 2017, those who manufacture, use, handle, store and transport hazardous substances in the workplace will need to follow the new Health and Safety at Work (Hazardous Substances) Regulations 2017 (Regulations).
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Tools, Plant & Equipment (Question 9)
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Are all tools, plant and equipment maintained, certified, tagged and tested to meet or exceed current compliance requirements.<br><br> Help guide: Where applicable it is expected you will state yes to this question. For more information visit. http://www.energysafety.govt.nz/appliances-fittings/electrical-appliances-fittings/operational-safety/test-tag-regime<br>Electrical equipment should be tested in accordance with AS/NZS3760 with procedures for maintaining plant and equipment including vehicles, lifting equipment such as lifting beams, chains and lifting devices should be tagged and tested. Harnesses and lanyards should also be regularly inspected tagged and tested, all plant and equipment should be fit for purpose as per the manufacturers specifications<br>
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Hazard Management (Question 10)
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Do you plan for significantly hazardous and/or critical risk activities?<br><br>If yes, please upload x1 example of your safe operating procedures including a current risk register <br><br>Help guide: Depending on the types of risks associated by the business, how does your organisation manage these risks. For more information visit. http://www.worksafe.govt.nz/worksafe/hswa/health-safety<br>Consider the following areas for your answer: Do you have a current risk register, are formal hazard and risk assessments carried out and documented, where those specific hazards and risks have been identified how are you managing them using appropriate controls.<br>Do you have procedures for eliminating or minimising risks? Do you carry out regular inspections or audits, if yes, an example can be up loaded, this may also include task analysis, safe work method statements or Job safety analysis.<br><br>Examples:<br>Risk register <br>Task analysis <br>Inspection and Audit process <br><br>
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Training and Competency (Question 11)
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Are you and your workers trained and competent for all aspects of the work you are/will carry out?<br><br>If yes, please provide a competency matrix as evidence, this may include <br>Certificates <br><br>Help guide: Please supply evidence of training and or qualifications/ certification / trade qualifications relevant to the work you may do. Examples: Confined space entry, height safety training, electrical certificate, NZQA unit standards, chainsaw certificate, first aid, approved handler, vehicle licenses (WTR) Trade qualifications for electrical registration, gas fitter license, arborist.<br><br>Workers who will undertake specific (high risk) work must receive formal training in all relevant areas, evidence of this must be provided <br><br>Examples:<br>Training and competency register <br>Qualifications <br>Certifications <br>Photo ID & Membership cards, including drivers licences <br>
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Sub-Contractors (Question 12)
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Do you engage sub-Contractors?<br><br>If yes, please provide their company or name and relevant contact information via the comments section or use the document up load option<br> <br>Help guide: Do you engage or use other workers, sub-contractors, volunteers, people on work experience, employees of a labour hire company
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Engagement (Question 13)
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How do you manage the safety of any subcontractors you may engage?<br><br>If you do not engage with sub-contractors, please select not applicable<br><br>Help guide: Do you clearly define roles and responsibilities to these workers, and do you have a system to monitor these workers on a regular basis, do you have regular communication with them<br><br>
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Health Monitoring (Question 14)
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Do you carry out health monitoring<br><br>If yes, please up load a copy <br><br>Help guide: Where workers are not exposed to hazardous conditions, (for example Asbestos or certain hazardous conditions) please select the appropriate option below and this question will be marked as N/A. For more information visit http://www.worksafe.govt.nz/worksafe/information-guidance/all-guidance-items/hswa-fact-sheets/health-monitoring-
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Insurance (Question 15)
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Please provide details of your employer’s liability insurance and your public liability insurance <br><br>Guidance: If you are not required to provide this documentation or do not have access to the relevant information, please provide explanation in the comments section and we will advise procurement
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WorkSafe
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Has your organization been investigated by WorkSafe New Zealand during the last 3 years <br><br>Please select from the response options provided. <br><br><br>Additionally, you are welcome to provide any relevant information <br>
Disclaimer
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Disclaimer I understand I may be required to provide additional information to support my application. I understand information provided on this form will be collected and held by the Health & Safety Advisor I certify that to the best of my knowledge the information given above is correct.
