Mode 2 Contractor HSE Pre-qualification Questionnaire

TO BE COMPLETED BY THE CONTRACTOR AND VERIFIED/SCORED BY THE HSE ASSESSOR DURING THE SITE VERIFICATION:

Name of the Company

Address

:
:

Name of the Person (Including position, title & e-mail

address) completing this Checklist

Nature of Business
Telephone #
Fax #

:
:
:

Statement: I, certify that the details provided in this assessment are true and correct to the best of my knowledge.
Signature with Date

SR.
NO

EVALUATION FACTORS
LEADERSHIP AND COMMITMENT
1.1 Commitment to HSE through Leadership

CHECKLIST

Are senior managers personally involved in HSE

management?

Is there evidence of commitment at all levels of the

organization?

Is there a positive culture towards HSE matters?

Necessary manpower and financial resources are

provided by management.
High profile tours by senior management during last
year
Monthly HSE meetings
Quarterly KPI reviews
Follow-up action plan for discrepancies found during
audits & investigations
Reward scheme for reporting HSE improvements
incentive schemes
HSE campaigns
HSE competitions/ quizzes
Behavioral-based Safety
HSE suggestion program

HSE POLICY AND STRATEGIC OBJECTIVES

2.1 HSE Policy documents
2.2 Availability of Policy statements to employees

Does your company have an HSE Policy document? (If

yes please attach a copy).
Who has overall and final responsibility for HSE in your
organization?
Who is the most senior person responsible for this
policy being implemented at premises/ sites where his
employees are working? (Provide name, title and
experience).
Itemize the methods by which you have drawn your HSE
Policy statement to the attention of all your employees?

Policy contains Company main business?

Policy contains Commitment to protect employees
including others?
Policy contains Compliance with local and international
legal laws.
Policy contains Commitment to assess risk for all
activities before execution
Policy contains Commitment to protect the
Environment
Policy contains Commitment for continual
improvement.
Policy Endorsed by company GM
Policy displayed on boards
Is there Monthly HSE meeting
HSE booklet
HSE induction
Are Bojectives Documented
Are the Objectives SMART
Are the Objectives Consistent with HSE policies?

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

yes please attach a copy).

Who has overall and final responsibility for HSE in your
organization?
Who is the most senior person responsible for this

SR. policy being implemented at premises/ sites where his

EVALUATION
FACTORS
NO employees are working?
(Provide
name, title and
LEADERSHIP AND COMMITMENT
experience).
Itemize the methods by which you have drawn your HSE
Policy statement to the attention of all your employees?
What are the arrangements for advising employees of
changes in the HSE Policy?

CHECKLIST
Do Objectives address legal requirements, HSE risks
Do Objectives address Technological options
Are the Objective Financially supported
Are the Objective Operational
Are trhey inline with business requirements
Do they consider Views of interested parties.
Is there Continual improvement
Is there a plan (Who will do what, how and when)
Are the Objectives Reviewed in regular basis
Policy is posted on all sites and visible to all employees
Are employees adviced of any change in the policy
Policy is communicated to all employees during safety
meetings

ORGANIZATION, RESOURCES AND COMPETENCE

3.1 Organization - commitment & communication
Company Organization Chart
Internal & External communication procedure
Hierarchy of HSE meetings

How is management involved in HSE activities, objective

setting and monitoring?
Type of meetings, how often, who attend, what agenda.
How is your company structured to manage and
communicate HSE matters effectively?
What provision does your company make for internal
HSE communication meetings?

HSE induction for new employees

Communication of Major hazards & Risk Assessment
to staff
Management involved in defining HSE Critical
activities, setting HSE KPIs, Auditing & inspection and
tool box talks meetings.
Staff informed about their HSE management
representative.
Staff informed about their HSE employee
representative

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO
3.2

EVALUATION FACTORS
CHECKLIST
LEADERSHIPand
AND
COMMITMENT
Competence
training
of managers/ supervisors/ senior site staff/ HSE advisors
Roles & Responsibilities defined & documented
Resources availability

Have the managers and supervisors at all levels who

will plan, monitor, oversee and carry out the work
received formal HSE training in their responsibilities to
conducting work to HSE requirements.
If YES please give examples. Where the training is given
in-house please describe the content and duration of
courses.
3.3 Competence and general HSE training

Competencies requirements identified for HSE critical

activities
Competence assurance system
Training needs analysis
Training Matrix
Yearly training plan
Training records
Training evaluation system

Specifications for skills, experiences, knowledge level

and personnel qualification for key positions.

What arrangements does your Company have to ensure

new employees have knowledge of basic industrial HSE,
and to keep this knowledge up to date?
What arrangements does your Company have to ensure
new employees have knowledge of your HSE policies
and practices?
What arrangements does your Company have to ensure
new employees have been Instructed and given
information on specific hazards arising out of the work
being undertaken? What training do you provide to
ensure that all employees are aware of Group company
requirements?
What arrangements does your Company have to ensure
existing staff HSE knowledge is up to date?
(If training is provided in-house please give details of
content)

Competencies requirements at recruitment stage

Competency evaluation at recruitment stage
HSE induction program
Awareness program for HSE roles /Responsibilities
Awareness program for HSE risks & impacts relevant
to their workplace / activities
Awareness program for Conforming to policy,
procedures and HSEMS
Awareness program for Consequences from deviating
from procedures
HSE training records
Staff attended Basic Fire Fighting, H2S & B/A,
Emergency Response and PTW Courses
Staff Performance appraisal
Tool box Talks

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO

CHECKLIST

EVALUATION FACTORS
LEADERSHIP
AND COMMITMENT
3.4 Specialized
Training
3.5 HSE qualified staff additional training
Areas Identified?

Have you identified areas of your Company where

specialized training is required to deal with potential
dangers? (If YES please itemize and provide details of
training given)
If the specialized work involves radioactive, asbestos
removal, chemical or other occupational health hazards,
how are the hazards identified, assessed and
controlled?.
Does your company employ any staff who possesses
HSE Qualifications that aim to provide training in more
than the basic requirements?

Training given
Given to all affected peopole
Hazard identified
Hazard conrol procedure & Plan
List of HSE critical activities
Availability of qualified HSE staff
Competency assurance system in place.
Critical roles and responsibilities identified
Specialized training for critical activities.
PTW system in place and working effectively

3.6 Assessment of suitability of Sub-Contractors / other companies

Standard Criteria for selection of Subcontractors

How do you assess:

HSE competence
HSE record of the subcontractors and companies with
whom you place contracts?
Where do you spell out the standards you require to be
met?
How do you ensure these are
met and verified?

Subcontractors selection evaluation process

Subcontractors on site performance monitoring

evaluation process

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO

EVALUATION FACTORS
4 RISK
LEADERSHIP
AND COMMITMENT
EVALUATION
AND MANAGEMENT
4.1 Hazards and effects assessment

What techniques are used within your Company for the

identification, assessment, control and recovery of HSE
hazards and effects?

CHECKLIST

HSE Risk Assessment procedure

Methodology used (HAZOP, HAZID, JSA, QRA,
HSEIA, Fault Tree Analysis)
the assessment of:
Documented HSE risk assessment register covering
Routine & non-routine activities
Documented HSE risk assessment register covering
Persons access to the workplace
Documented HSE risk assessment register covering
Human behavior & human factors
Documented HSE risk assessment register covering
Infrastructure, equipment & materials
Documented HSE risk assessment register covering
Changes in the organization
Documented HSE risk assessment register covering
Design of work area, installations, processes,
machinery.
Hazards, effects and aspects ranking system
Significance evaluation methodology
Set of controls or risk reduction measures to ALARP
Active follow up system for actions close-out.

4.2 Exposure of the workforce

Workforce aware of potential hazards at work area.

Do you have in place any systems to monitor the

exposure of your workplace to hazards like chemicals or
physical agents?

Performance indicators in place for all HSE critical

activities
Regularly monitoring & measuring of performance
against each indicator
HSE Exposure limits
Health monitoring system
Environmental monitoring system
Medical fitness standards & certificates
Medical Check Up
HSE Performance monitoring records
Environmental discharges / emissions records
HSE Exposure monitoring and records

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO

EVALUATION FACTORS
4.3 Handling
LEADERSHIP
AND COMMITMENT
of chemicals

How is your workforce advised on the hazards

encountered in the course of their work?

CHECKLIST
List of chemicals used.
MSDS
Hazard Communication methods
Tool Box Talks
Induction training
Awareness courses
Actions to reduce risks allocated to specific personnel
Staff familiar with their roles in controlling hazards.
Employee performance review

4.4 Personal protective equipment

What arrangements does your company have for

provision and maintenance of PPE both standard issue,
and that required for specialized activities?

4.5

PPE procedure
Job PPE requirements
PPE specification
PPE quality inspection on delivery
Training of the use of PPE.
PPE usage monitoring program on site.
Stock inventories
Replacement policy

Waste Management
Waste management procedure
Identification of Hazardous & non-hazardous waste
Classification of wastes

Does your company have in place systems for

Segregation of Wastes
identification, classification and management of waste? Disposal of wastes

Waste Minimization program

Waste Recycling program
Waste re-use program

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO

CHECKLIST

EVALUATION FACTORS
5 PLANNING,
LEADERSHIP
AND COMMITMENT
STANDARDS
AND PROCEDURES
5.1 HSE or Operations Manuals
HSEMS Manual

Do you have a company HSE manual (or Operations

Manual with relevant sections on HSE), which describes HSEMS procedures
in detail your Company approved HSE working practices
HSEMS work instructions
relating to your work activities?
(If the answer is YES please attach a copy)
System for producing, updating and disseminating
How do you ensure that the working practices and
procedures used by your employees on-site are
consistently in accordance with your HSE policy
objectives and arrangements?
5.2

Control of Documents process

HSEMS Compliance assurance process

Equipment control & Maintenance

How do you ensure that plant and equipment used by

your employees within your premises, on-site, or at
other locations, is correctly managed and maintained in
a safe working condition?
5.3

standards
HSE critical activities procedures

Maintenance policy
List of HSE critical activities / equipments
Inspection and maintenance system
Planned maintenance program
Preventive maintenance program
Inspection and maintenance records
Equipment history record
Equipment certification records

Standards
Where do you spell out the standards you require to be
met?
How do you ensure these are met and verified?
Is there an overall structure for producing, updating and
disseminating standards?

Legal and other regulatory standard procedure

Identification and access to legal standards
Updated List of regulatory standard and other
requirements.
System for evaluating compliance with regulatory
standards and other requirements.

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO
5.4

CHECKLIST

EVALUATION FACTORS
LEADERSHIP
AND COMMITMENT
Road
Safety Management
How is road safety managed and what arrangements
does your company have for combating road and
vehicle incidents?

Road Safety Policy

Road Safety Management
Road Safety procedure
drivers performance Monitoring system
Vehicles maintenance
Defensive driving training

6 IMPLEMENTATION AND MONITORING

6.1
6.2

Management and performance monitoring of work activities

HSE performance achievement awards
What arrangements does your company have for
supervision and monitoring of HSE performance?
What type of performance criteria are used in your
company; give examples?
What arrangements does your company have for
communicating the results and findings of this
supervision and monitoring to your management and
employees?
Has your Company received any award for HSE
achievement?

Non-conformity, corrective and preventive action

procedure
HSE Performance & evaluation of compliance
procedure
HSE Key Performance Indicators
HSE performance monitoring system
Qualitative and quantitative KPIs
Annual Performance review
Calibration program for equipment used for
measurement
HSE performance awards received
Methods of communicating HSE performance results to
staff

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

SR.
NO

EVALUATION FACTORS
LEADERSHIP
AND COMMITMENT
6.3 Statutory
Notifiable
incidents / dangerous occurrences
6.4 Improvement requirement and Prohibition Notices

CHECKLIST

Last 5 years HSE statistics

Has your company suffered any statutory notifiable

incidents in the last three years (safety, occupational
health and environmental)? Answer with details
Last 5 years major incident
including dates, most frequent types, causes and followup preventative measures taken..
Has your company suffered any improvement
Last 5 years Statutory notification records
requirement or prohibition notices by the relevant
national body, regulatory body for HSE or other
enforcing authority or been prosecuted under any HSE
Last 5 years Prohibition notices records
legislation in the last three years? (If your answer is
YES please give details.)?
6.5 HSE performance records
HSE performance records include LTI,
HSE performance records include Non-LTIs
HSE performance records include Restricted work
cases
HSE performance records include LTI Frequency Rate

Have you maintained records of your incidents and HSE

performance for the last five years?
(If YES, please give following details for each year,
number of Lost Time Injuries, number and type of other
injuries e.g. MTC, RWC, F.A., total hours worked by
workforce for each corresponding year, frequency rates,
your company definition of a Lost Time incident).
How is health performance recorded?
How is environmental performance recorded?
How often is HSE performance reviewed? By whom?

HSE performance records include total hours worked

by workforce for each corresponding year,
HSE performance records include HSE performance
against targets set.
HSE performance records include Reports of audits &
reviews
HSE performance records include Audit tracking data
HSE performance records include Complaints & follow
up actions
HSE performance records include Ill health
performance records
HSE performance records include Environmental
performance records

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

number of Lost Time Injuries, number and type of other

injuries e.g. MTC, RWC, F.A., total hours worked by
workforce for each corresponding year, frequency rates,
your company definition of a Lost Time incident).
How is health performance recorded?

SR.
performance
recorded?
EVALUATION
FACTORS
NO How is environmental
LEADERSHIP AND COMMITMENT
How often is HSE performance reviewed? By whom?

CHECKLIST
HSE performance records include Emergency drills
performance records
HSE performance records include HSE training
performance records
HSE performance records include Follow up actions
from corrective and preventive actions
HSE performance records include Evaluation of
compliance records
Frequency of HSE performance reviews

6.6 Incident investigation and reporting

Who conducts incident investigations?

Incident reporting & investigation procedure

Incident investigation records
Near Miss Reports
Potential Incident Reports
Actions raised reviewed through Risk Assessment prior
implementation
Follow up of corrective and preventive actions taken

How are the findings of an investigation, or from a

relevant incident occurring elsewhere, communicated to
your employees?
Review of the effectiveness of the corrective and
Are near misses reported?

preventive actions taken.

Members involved in incident investigation
Method of communicating the Investigation results.
System for Sharing lessons learnt from incidents

7 AUDIT AND REVIEW

7.1 Auditing
Internal Audit Procedure
Planned Yearly audit program covering all activities
areas including HSEMS, facilities, operations, unsafe
acts & projects.
Audit team competencies in term of responsibilities,
experience, impartially & auditing skills.

Do you have a written procedure on HSE auditing and

how does this procedure specify the schedules and
standards for auditing (including unsafe act auditing)?
Do your company HSE Plans include schedules for
auditing and what range of auditing is covered?
How is the effectiveness of auditing verified and how
does management report and follow up audits?

Documented Internal audit reports

Audit findings recorded, prioritized and corrective
/preventive actions identified and responsibility
assigned.
Documented Action Tracking system of Internal audit
findings to final close-out

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer

Do you have a written procedure on HSE auditing and

how does this procedure specify the schedules and
standards for auditing (including unsafe act auditing)?

SR.
HSE Plans include
schedules for
EVALUATION
FACTORS
NO Do your company
auditing
and what
of auditing is covered?
LEADERSHIP
ANDrange
COMMITMENT
How is the effectiveness of auditing verified and how
does management report and follow up audits?

CHECKLIST
Review of the effectiveness of the corrective and
preventive actions taken by senior management
Senior Management reviews of HSEMS cover Meeting
frequency
Senior Management reviews of HSEMS cover
Management involved
Senior Management reviews of HSEMS cover Meeting
agenda based on international standard
Senior Management reviews of HSEMS cover
Recommendation for improvement
Output of the review

8 HSE MANAGEMENT -ADDITIONAL FEATURES

8.1 Memberships of Associations
8.2 Additional features of your HSE Management
Does your Company hold HSE membership of, or
actively support any industry or trade organization?
Does your Company have any other HSE features or
arrangements not described elsewhere in your response
to the questionnaire?

HSE membership
HSE Incentive program
Certified ISO 14001
Certified OHSAS 18001
Reward Schemes
Suggestion system for continual improvement.
Any other HSE features or arrangements.

CONTRACTOR RESPONSE.
Available Please provide the supprting
(Yes/No) document for any YES answer