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166/02/SR/VI/2015
Provision of Integrated Engineering Services
ENVELOPE I APPENDICES
APPENDIX B.4
HSE QUESTIONNAIRE
FORM
Date : _____________________________________________
CUE KALIMANTAN Pte Ltd desires to continually improve their HSE performance. The
Company recognizes that vendors and suppliers contribute a large amount to our overall
HSE efforts and performance. We therefore wish to select organizations that have a
common goal and similar approach to our business principles. Only those contractors who
demonstrate management leadership and compatible systems, resulting in good safety and
health performance shall be placed on our approved vendors/service providers list. We
therefore request that you complete this HSE screening form and return it as instructed.
Those organizations successfully pass this initial screening process will be included on
COMPANY approved vendor/service provider list.
COMPANY expects that the applicant (Vendor/Service Provider) to:
Have a documented health and safety program (HSE Management System) that
meets the requirements of the goods or services that you are offering at this
screening stage.
Have a program for implementing the requirements of health and safety program
(HSE Management System)
Have a commitment to screen and apply these standards to any sub-contractor that
vendor/supplier of services may use.
COMPANY reserves the right to inspect and interview any of your personnel with the
purpose of verifying the correctness of your response.
Any falsification of facts will result in rejection / disqualification of the Vendor/Service
Provider from the approved Vendor/Service Supplier List.
Following completion and return of this documentation the submission will be evaluated.
However, marking of the submission will not occur until the data has been verified by a
COMPANY representative, following which the overall screening will be objectively marked.
The passing mark required for registration as an approved Vendor/Supplier of Services is 2/3
of the maximum score.
Successful Vendors/Supplier of Services will be given a certificate of approval with a validity
period of 2 years.
b. Who has overall and final responsibility for HSE in your organisation?
c. Who is the most senior person in the organisation responsible for this policy being carried out on
site where his employees are working? Provide name, title and experience.
b. What are your arrangements for advising employees of changes in the policy?
2. RISK ASSESSMENT
What techniques are used within your COMPANY for the identification, assessment, control and
recovery of risks, hazards and effects?
3.2 Standards
a. Where do you spell out the standards you require to be met?
b. What arrangements does your COMPANY have to ensure new employees and contractors also
have knowledge of your HSE policies and practices?
c. What arrangements does your COMPANY have to ensure new employees have been instructed
and have received information on any specific hazards arising out of the nature of the activities?
What training do you provide to ensure that all employees are aware of COMPANY
requirements?
d. 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).
b. If the specialised work involves hazardous materials such as radioactive, asbestos, chemical or
other occupational health hazard, has the hazard been properly identified, assessed and
controlled?
4.3 Competence and Training of managers/ supervisors/ senior site staff /HSE advisers
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 with respect to conducting work to HSE
requirements? If YES please give details. Where the training is given in-house please describe the
content and duration of courses.
3.2 Standards
b. What form of Occupational health, safety and/or environmental qualification does your
specialised HSE staff have?
5 OPERATIONAL CONTROLS
5.1 HSE and operations manuals
a. Do you have a COMPANY HSE manual (or Operations Manual with relevant sections on HSE)
which describes in detail your COMPANY approved HSE working practices relating to your work
activities?
If the answer is YES please attach a copy of supporting documentation
b. 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?
b. Does your company ensure that all jobs and equipment necessary for the work are used safely,
are in good condition and meet with local laws, rules and regulations?
5 OPERATIONAL CONTROLS
Does your COMPANY have in place systems for identification, classification and management of
waste, including grey water and raw sewage?
6. EMERGENCY PREPAREDNESS
a. Provide a description of your COMPANY emergency procedure.
b. Please provide examples of a recent Emergency Response Plan and an Oil Spill Contingency
Plan
8. COMMUNICATIONS
a. How is your COMPANY structured to manage and communicate HSE effectively?
b. What provision does your COMPANY make for HSE communication meetings?
b. What type of performance criteria are used in your COMPANY; give examples
c. What arrangements does your COMPANY have for passing on any results and findings of this
supervision and monitoring to your:
- BU/SU Heads
- Site employees?
6. EMERGENCY PREPAREDNESS
How often is HSE performance reviewed? By whom?
b. How are the findings following an investigation, or a relevant incident occurring elsewhere,
communicated to your employees?
9.4 Audit
a. Do you have a written policy on HSE auditing and how does this policy specify the standards for
auditing (including unsafe act auditing)?
b. Do your COMPANY HSE Plans include schedules for auditing and what range of auditing is
covered?
c. How the effectiveness of auditing is verified and how does management report and follow up
audits?
10 COMPLIANCE
10.1 Statutory notifiable incidents/dangerous occurrences
Has your COMPANY suffered any statutory notifiable incidents in the last five years (safety,
occupational health and environmental)? (Answers with details including dates, most frequent types,
causes and follow-up preventative measures taken.)
f. Please provide a copy of the contents index of the Quality Manual and a copy of a recent
Internal Audit Report
Signature:
Name: ______________________________
Title: ______________________________
Date: _______________________________