Contractor Selection Questionnaire

Please include, where requested, any supporting documents marked clearly on all
enclosures the name of your Company and the number of questions to which they
refer. Large documents may be provided in electronic format.
This document will be reviewed every 2 years.

The completed questionnaire should be returned to:

Estates Department
Staffordshire University
College Road
Stoke on Trent
ST4 2DE

The information you give will be treated as confidential

Please indicate the type of work in which your Company specialises/has experience
(can be more than one selection).

Please tick if appropriate

Please tick if appropriate

Asbestos Removal

Laboratories:

Builders (New Build)

Biological

Builders (Refurbishment)

Chemical

Carpentry and Joinery

Engineering

Civils

Radiation

Confined Space

Other Laboratories (please specify)

Data and Telecoms Cabling

Demolition
Electrical LV

Pressurised Gases:

Electrical HV

Industrial Gases

Fire/Burglar Alarm
Installation

Pressure Vessels

Gas Fitters

Please specify any other work:

Heating and Ventilating

Engineers
High Pressure Steam
Painters
Plasterers
Plumbers
Lifts
Roofing Contractor
Scaffolding

Section 1

CONTRACTOR SELECTION QUESTIONNAIRE

Company Information

Please provide the following details about your Company

Name:
Address:
Turnover:

Tel No.

Email:

Web address:

Fax:

No of Employees:

Companies House Registration:

Date of Formation or Age of

Company:

Names of Directors:
Please confirm whether any of the above named Directors have been convicted
of an offence concerning their professional conduct:
Yes
No

1
2

Please attach details of your organisations experience in the

area that you are tendering for, include details of previous
contracts and referees.
Please give details of 2 referees:
Referee 1
Referee 2
Name:
Name:
Company:
Company:
Address:
Address:

Companys main area of work:

Is your organisation or any member of staff a member of any

trade or professional organisation?
If so please provide details of membership of any such
organisation.

Insurance:

Insurer:

Employers Liability Insurance held:

Enclose a copy of your policy

Policy No:
Extent of Cover:

Attached
Yes
No

CONTRACTOR SELECTION QUESTIONNAIRE

Insurer:

Public Liability (3rd party) insurance held:

Enclose a copy of your policy

Policy No:
Extent of Cover
(minimum cover
10m)

Please provide details of your new Construction Industry

Scheme Certificate or Registration Card.
Alternatively, if you are a limited Company, you may wish to
present a Certifying Document, which should contain the
following information:
A statement that your Company is the user of the valid
certificate (CIS5).
The Companys registered address and Company
registration number.
Certificate number and the address of the issuing Inspector
of Taxes.
Expiry date of the Certificate.
Details of the special bank account or accounts.

Do you anticipate using subcontractors? If so, how do you assess their health
and safety competence?

Section 2
8

Health & Safety Information

Please provide the names and job titles of those people in your organisation
with the following responsibilities: The person who has ultimate responsibility
for health and safety:
Name:

Job Title:

The person responsible for the day to day management aspects of on-site
work:
Name:

Job Title:

CONTRACTOR SELECTION QUESTIONNAIRE

If you employ five or more employees, please attach a copy of

your companys most recent health and safety policy (including
general statement of intent, organisation for health and safety
and working arrangements).

Contractors that do not have health and safety policies must

demonstrate their commitment to health and safety by having
the most senior person in the organisation sign and date the
Commitment to Health and Safety at Work (attached) and
return a copy to the University.
Give details of how your health and safety policy is maintained:

10

Competent Health & Safety Adviser

State the name of the person or people who provide your competent health
and safety advice.
Name:
Address:

Tel No:

Email:

11

Describe their health and safety qualifications, experience or relevant training

that enables them to undertake this responsibility:

12

If your competent advice is from outside your Company, describe the role they
play in the management of health and safety in your Company and describe
the capacity in which your Company has employed them in the last year.

CONTRACTOR SELECTION QUESTIONNAIRE

13

Please describe any other sources you may use to get health and safety
information:

14

How do you monitor the health and safety performance of your:

Company:

Employees:

Sub-Contractors:

15

How do you ensure that employees are kept up to date on health and safety
matters?

16

How do you assess sub-contractors health and safety competence?

(e.g. Contractor Selection Questionnaire - please attach copy)

17

How do you ensure that plant and equipment is in a safe and useable
condition?

18

Please enclose copies of any six assessments undertaken for

similar projects:

General Risk Assessments, as required by the

Management of Health and Safety at Work Regulations
1992.

Safety Data Sheets and COSHH Assessments for all

substances that you propose to use (if applicable).

Any other relevant assessment (e.g. manual handling,

noise)

Attached
Yes
No

19

CONTRACTOR SELECTION QUESTIONNAIRE

Health & Safety Training, Information and Instruction

How does your Company provide relevant health and safety
training, information and instruction to its employees:

20
21
22

Attached
Yes
No

Attach copies of training records for your company employees

likely to work on Staffordshire University Sites.
Does your Company provide induction training for new
starters?
Does your Company provide written instructions for your
employees e.g.: a safety manual. If yes, attach copies of
instructions relevant to work on Staffordshire University Site.
Describe health and safety training given to Managers in the last three years.

Describe the health and safety training given to workers in the last three years.

What are your plans for training during the next twelve months?

23

Asbestos

Yes

No

Have you trained your employees about asbestos, where it

may be found and what it might look like?
Have your employees been trained in the action to take if
they find materials they suspect may contain asbestos?
If YES (in either case) attach evidence of training.
24

Attached
Yes
No

Accident Reporting
Describe how your company reports and investigates accidents.

CONTRACTOR SELECTION QUESTIONNAIRE

Complete the following table of accident statistics

Year
Fatal
Major Injury Non Reportable
+ over 7 day
This year (to date)
Last year (full year)
Year before last (full
year)
Give an example of any of the above accidents which were investigated and
what actions, if any, arose from that investigation.

25

Please provide details of any accidents/incidents to employees and non

employees reported by or on behalf of your organisation to the Health & Safety
Executive (HSE) during the last 3 years (as required by the Reporting of
Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).

26

Have any enforcement notices been issued or legal

proceedings taken against your organisation by the Health &
Safety Executive (HSE) in the last 3 years? If so please give
details:

27

28

Yes

No

(Please note that this will be checked against the

HSE prosecutions and notices database)
How do you ensure health and safety procedures are followed by staff and
sub-contractors?

Please provide details of how often and by whom safety inspections will be
carried out.

CONTRACTOR SELECTION QUESTIONNAIRE

29

Is your Company a member of any health and safety

organisations e.g.: ROSPA, British Safety Council, or IOSH?

Yes

No

Yes

No

If so give details:

Is your company a member of the North Staffordshire

Health & Safety Group? (www.nshsg.org.uk)
If yes, how many meetings/events have you attended over
the last twelve months?

30

I certify that the information supplied is accurate, to the best of my knowledge. I

understand that false information could result in my Companys exclusion from the
Approved contractors List.
Name:

Signed:

Position:

Dated:

Before returning this questionnaire, please ensure that you have:

* Answered all questions
* Enclosed all documents

COMMITMENT TO HEALTH AND SAFETY AT WORK

Our Company is committed to ensuring that the health, safety and welfare
of my employees, University staff, students and visitors is not adversely
affected by the work my company carries out.
We will:
Control health and safety risks arising from our work activities.
Consult with our employees on matters affecting their health and safety.
Provide and maintain safe plant and equipment.
Ensure safe handling, use and storage of substances.
Provide the necessary information, instruction training and supervision to
our employees and ensure they are competent to do the work given to
them.
Endeavour to prevent all accidents and cases of work-related ill health.
Provide a safe and healthy place of work.
Review and revise this commitment as necessary and at intervals not
exceeding two years.
Provide adequate resources to ensure health and safety is managed
properly.

Name:

Position:

Signature:

Dated:

10