Reference HSMS 3.

37
Issue no. 2
Date Dec 2013
Author D Bowles
Approved D Miles
CONTRACTOR SAFETY, HEALTH AND ENVIRONMENT
ASSURANCE QUESTIONNAIRE
Contractor Company Name:
Burtons Contact:
Guideline for completion:
 You are requested to complete this questionnaire to the best of your ability.
 The answers will be used as the basis for a review with your Burtons’ site contact, during which you will agree a way
ahead in building your safety arrangements to the level appropriate to the type of work that you perform for Burtons.
 Not being able to answer ‘yes’ to a question is not a bar to working with Burtons. For smaller contractors especially,
some requirements may be non-applicable – this will be decided by Burtons in consultation with you.
 There is no requirement to produce any paper evidence at this stage, other than where specifically indicated. After
review, you may be asked to provide specific arrangements or records.
 Where possible, please provide electronic copies of certificates, policies and supporting evidence.
QUESTION Notes on Answers
POLICY
Provide a copy of your health and safety policy Provide Copy
statement
Provide a copy of your environmental statement. Provide Copy
Please state who has signed these. Name:
Position:
ORGANISATION
Indicate whether you utilise a health and safety Name:
professional. Position:
Please provide details of their qualifications. Qualification:
ARRANGEMENTS Yes/No Comments
Do you have a formal health and safety System?
Is the system accredited to a recognised standard? If yes, please state standard:
Does the safety management system include formal
arrangements covering:
- Accident reporting and investigation
- Incident reporting and investigation
- Risk assessments which have identified the key risks
associated with your work activities
- A safety inspection of work areas at contractors’
premises.
- Safety inspections of contract work areas at clients
premises
- The planned inspection and maintenance of specific
equipment
- The use of personal protective equipment for
specified tasks
- Discipline for safety compliance issues
- Consultation with employees
- Safety briefings to all employees
- Training for managers/supervisors in critical aspects of
safety management appropriate to the company’s
activities
- Training for employees in critical aspects of safety
appropriate to the risks they face and pose to others.

THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED

 Reference HSMS 3.37
Issue no. 2
Date Dec 2013
Author D Bowles
Approved D Miles
CONTRACTOR SAFETY, HEALTH AND ENVIRONMENT
ASSURANCE QUESTIONNAIRE
- Established written rules and practices for critical
tasks.
- A permit to work system
- Assessing job specific risk and writing accurate
method statements
- Emergencies, first aid etc.
- Vetting of sub-contractors
- Internal auditing of the management system
- External auditing of the management system
LICENSING Yes/No
Does any aspect of your work have to be licensed by a Provide
local authority or other licensing body? licenses/authorisations:
FOOD SAFETY Yes/No
Have any of your employees attended any food safety Provide copies of any certificates
training courses?
TRADE ACCREDITATION/PROFESSIONAL BODIES Yes/No
Are you a member of any trade body, which provides Name:
any type of active accreditation/audit/monitoring?
If yes, please state.
EXPERIENCE
What experience do you have in the type of work you
propose to do/are doing?
INSURANCE
Please enclose copies of your public/third party liability Provide copies.
and employer’s liability insurance certificates.
ENVIRONMENT Yes/No Comments
Do you have any formal Environmental Management
System?
Have you had any environmental incidents over the last
5 years?
If so, please provide brief description.
Do you intent to be transporting your waste from site?
If so, please provide a copy of your waste carrier’s
license.
ACCIDENT DATA
Provide accident statistics below Provide details for current year and 3 years previous
Year Number of Number of over 3 Number of HSE Number of HSE Reportable Injury
Employees day injuries ‘Major Injuries’ Fatalities Rate/100,000 Hours*

*Reportable Rate = No of HSE reportable injuries/number of hours worked * 100,000

This document has been completed to the best of my knowledge.

Completed By:

THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED

 Reference HSMS 3.37
Issue no. 2
Date Dec 2013
Author D Bowles
Approved D Miles
CONTRACTOR SAFETY, HEALTH AND ENVIRONMENT
ASSURANCE QUESTIONNAIRE
Position:
Date:

THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED