CONTRACTOR MANAGEMENT SYSTEM

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1 CONTRACTOR MANAGEMENT SYSTEM NEW CONTRACTOR QUESTIONNAIRE Version 1 A Centre of Regional Excellence. December 2011

2 QUESTIONNAIRE TO BE RETURNED TO THE RISK MANAGEMENT SERVICE UNIT WITH SUPPORTING DOCUMENTATION This questionnaire has been prepared to assist contractors to demonstrate their ability to manage Work Health and Safety (WHS Act 2011) and have the appropriate insurance and Work Cover registration requirements. Information submitted in this questionnaire will be treated as confidential unless it is required to be disclosed by law. 1. PERSONAL/FIRM S INFORMATION Name of Contractor: Contact Person: Postal Address: Telephone and Facsimile: BH: Mobile: AH Facsimile_ 2 CONTRACTOR S QUALIFICATION AND RESOURCES 2.1 Contractor s years in business as a Contractor under its present business name? Plant and Equipment to be employed on performing these services: Item Make Model Year etc. Activity (including backup) 2.2(a) Contractors Current Schedule of Machinery Rates. Please provide a detailed copy of your Schedule of Rates for Plant and Machinery. Terms 7 Conditions to be included (if applicable). 2

3 2.3 Details of any Sub-Contractors intended to be employed and for what portion of the service: Name and Address Qualifications/Experience Service/Activity 2.4 If Sub-Contractors are employed do you accept full responsibility for the work performed? Do you supply: Materials Equipment Yes Yes No No 2.6 Contractor s Depot/Office location (if applicable):

4 3. INSURANCE 3.1 Public Liability Insurer: Address: Contact Person: Telephone Number: Facsimile Number: A Certificate of Currency from the insurer, not a broker, must be provided. 3.2 Motor Vehicle (if applicable) Insurer: Address: Contact Person: Telephone Number: Facsimile Number: A Certificate of Currency from the insurer, not a broker, must be provided. 3.3 Professional Indemnity (If Applicable) Insurer: Address: Contact Person: Telephone Number: Facsimile Number: A Certificate of Currency from the insurer, not a broker, must be provided. 4

5 3.4 Contract Works (If Applicable) Insurer: Address: Contact Person: Telephone Number: Facsimile Number: A Certificate of Currency from the insurer, not the broker, must be supplied. PLEASE ENSURE THAT INSURANCE DOCUMENTATION SUPPLIED FULLY COMPLIES WITH WHAT IS REQUESTED. 5

6 4.CONTRACTOR ASSESSMENT QUESTIONNAIRE Date: Contract Number: Name of Contractor: 4.1 Legal name of business 4.2 Structure: Please tick - Sole Proprietor Partnership Company Trust Are you a registered Person Conducting A Business or Undertaking (PCBU) with Work Cover? YES NO If yes how many Workers? 4.4 Type of Work Performed: 6

7 4.5 Are you likely to Sub-Contract any of the work for the Lithgow City Council? If so, which tasks will be Sub-Contracted and to whom? 4.6 Do you accept full responsibility for the work performed? 5. WORK HEALTH AND SAFETY SYSTEM QUESTIONNAIRE 5.1 WHS Policy and Management YES/NO Do you/does the firm have a written company Work Health and Safety (WH&S) policy? If yes provide a copy of Policy. Comments: Do you/does the firm have a WHS Management System manual or plan? If yes provide a copy of CONTENTS page/s. Comments: Are WH&S responsibilities clearly identified for all levels of workers? 5.2 Safe Work Practices and Procedures Do you/does the firm have safe operating procedures or specific safety instructions relevant to you/your firm s operations? If yes provide a summary listing of procedures or instructions Comments: 7

8 5.2.2 Does the company have any permit to work systems? If yes provide a summary listing or permits: Is there a documented incident investigation procedure? YES/NO If yes provide a copy of a standard incident report form Are there procedures for inspecting and assessing plant (operated or owned) hazards? Are there procedures for storing and handling hazardous substances? Are there procedures for identifying, assessing and controlling manual handling risks? 5.3 OHS Training Are records maintained of all employee training and induction programs undertaken? If yes provide information of Certificates of Competency held to complete work activities at Annexure A. 5.4 Work Health and Safety Workplace Inspection 8

9 5.4.1 Are regular WH&S inspections undertaken at worksites? 9

10 5.4.2 Are standard workplace inspection checklists used to conduct WH&S inspections? If yes provide details or examples. YES/NO Is there a procedure by which workers can report workplace hazards? 5.5 Health and Safety Consultation Is there a workplace health and safety committee? Are workers involved in decision making over WHS matters? Are there worker-elected WH&S representatives. Comments: 5.6 OHS Performance Monitoring Is there a system for recording and analysing WH&S performance statistics? 10

11 5.6.2 Are employees regularly informed of your/your company s overall WH&S 11

12 performance? Have you/has the company ever been convicted of an OH&S or WHS offence? YES/NO 12

13 6. ENVIRONMENTAL MANAGEMENT List the activities that may impact on the environment and what measures will be put in place to prevent or minimise the impact: All reasonable steps and procedures must be taken to ensure operations are conducted with due regard to environmental issues and in compliance with all appropriate legislative requirements. 13

14 8. OTHER INFORMATION 8.1 Please provide copies of the following document templates regarding: 1. Return to Work Procedures 2. Accident Investigation Procedures 3. Tool Box Meeting Procedures 4. Manual Lifting Training Records 5. Hazard Reporting Procedures 6. List of all MSDS (Materials Safety Data Sheets) in use. 7. First Aid Training Procedures 8. First Aid Supplies Procedures 8.2 Ongoing expectations when work is conducted. Reporting Requirements 1. Daily and Weekly Inspections eg. Vehicle checklists 2. Working Reports eg Job Safety Analysis. 3. Fortnightly Toolbox Meeting Minutes PRIVACY & PERSONAL INFORMATION PROTECTION NOTICE By completion of this form you may be providing Council with personal information. Council will collect the information only for a lawful purpose directly related to the function of Council. Information provided to Council may be used in conjunction with any of Council s business operations. We will take reasonable care not to disclose personal information. Exempt documents may come under the Government Information (Public Access) Act

15 9. STATUTORY DECLARATION I declare that all information contained in this contracts pre-qualification form to be true and correct. Declared at.. in the State of New South Wales) on.. 20 ) Signature of Person Conducting Business or Undertaking:.. Name of Person Conducting Business or Undertaking:. Before Me: Full Name... Signature:... Address:... Qualifications... (This declaration must be witnessed by a member of the Police Force, Barrister or Solicitor, Pharmacist, School Principal, Doctor, Bank Manager, prescribed Public Servant, Justice of the Peace or any other person authorised to witness Statutory Declarations under section 107A (1) of the Evidence Act 1958.) 15

16 Annexure A WORK HEALTH AND SAFETY (Licences, Training, Certificates). Provide details of any relevant licences, permits or certificates held, or skills acquired or training undertaken by your staff. Person Relevant Certificates, Training or Licence Where possible, please provide copies of Certificates, licences, etc. 16

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