Application for Consultant Accreditation for Land Development Work

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1 Application for Consultant Accreditation for Land Development Work Do you need to complete this form? If you are a consulting engineering company and wish to seek accreditation with Barwon Water for Land Development Works you will be required to complete this application. Accredited consultants are responsible for the design and supervision of the construction, management of all health, safety and environment (HSE) aspects of the Land Development Works. This includes management of contractors, sub-contractors, as well as considering all HSE impacts in the design stage of a project. Details of Accredited consultants responsibilities are listed in the Land Development Manual (LDM) available online and as listed below. - Adherence to WSAA codes and Barwon Water Standards. - Accepting Barwon Water s role as quality auditor and facilitate any quality audits by Barwon Water. - Ensuring construction is conducted in accordance with the Civil Management Code or equivalent. - Retaining all records and documentation to demonstrate conformance to Barwon Water s quality requirements from commencement of works (or from the date of the letter of offer) to five (5) years and the works have been transferred to Barwon Water. - Accepting full responsibility and accountability for the design, construction and survey of all works to be taken over by Barwon Water. - Accepting the period on responsibility from the commencement of works (or from the date of the letter of offer) until five (5) years after the date of issue of certification of completion. - Ensuring only accredited contractors undertake the developer works construction. Consultant company details Company Name: Business or Trading Name (if applicable): Business address: Australian Company Number (ACN): Australian Business Number (ABN): Postal address: Phone: Fax: address: Web address Details of representative who will accept responsibility and quality of works on consultants behalf Name: Postal address: Position: Phone: Fax: Mobile Number: address: Business profile Please attach with this application any further details of directors, associates, and partners. Date Business Established: Directors, Associates, Partners Name Position Qualifications Page 1 of 5

2 Select type of accreditation you are seeking: Water Sewer Recycled Water Membership of associates Please attach with this application any further details of relevant affiliated associates. Details of the relevant associates the Applicant is affiliated with or a member of: Professional and technical employees who will be involved in providing services (exclude contract and temporary staff) Name Position Qualifications / Experience Key Personnel / Management Name Position Qualifications / Experience Professional Indemnity Insurance (min limit of liability $10 Million) Name of insured: Insurer: Sum Insured: $ Expiry date: Page 2 of 5

3 Victorian Workcover Authority Certificate Premium Paid: $ Expiry date: Accreditation Review Barwon Water will undertake regular consultant performance reviews. Barwon Water reserves the right to suspend or revoke accreditation if performance does not meet a satisfactory level. Barwon Water requires information supplied as part of this accreditation to be resubmitted at time of expiry. Failure to resubmit this information may result in a suspension of accreditation or accreditation review. Declaration (This declaration should be completed by a partner, director or other senior manager who have the authority to do so). I, the partner, director or senior manager of the above mentioned business, accept Barwon Waters conditions for accreditation (including responsibilities) and declare that the particulars shown herein are true and correct in every detail. Name: Signature: (Please print in BLOCK LETTERS) Date: / / Lodgement If you intend to post or fax this form please use the details provided below: Barwon Water Telephone: P O Box 659 Fax: Geelong Mandatory attachments Evident the Business is Quality Assured Professional Indemnity Insurance Certificate Victorian Workcover Authority Certificate Written details of practical experience Details of professional and technical employees Eligibility to members of the Institute of Engineers Australia Details of design and construction supervisors / managers Details of HSE management systems and completed questionnaire Page 3 of 5

4 Consultant HSE Questionnaire (Commercial-in-Confidence once completed) Barwon Water has a Health Safety Environment (HSE) contractor handbook which sets out the expectations for contractors and sub contractors working on Barwon Water assets. It is important this handbook is read prior to submitting the accreditation application. A copy of the HSE handbook can be found on our website. This questionnaire forms part of Barwon Water s consultant accreditation evaluation process and is used to provide an overview of the status of prospective Consultants OH&S management systems. Consultants will be required to verify their responses noted in the questionnaire by providing evidence of their ability and capacity in relevant matters. Certification The information provided in this questionnaire is an accurate summary of the company s occupational health and safety management system. Company Name: Name: Position: Signature: Date: Contract Description Brief description of the scope of works: List locations where work will be undertaken: List the major activities and types of work to be completed: OH&S Policy Yes No Is there a written health and safety policy? - If yes provide a copy of the policy Does the company have an OH&S Management System certified by a recognised independent authority (e.g. SafetyMAP, AS 4801:2001, CCF-IMS) Is there a company OH&S Management System manual or plan? - If yes provide a copy of the content page(s) Contractor Management Yes No Does the company have documented procedures for how it manages the health and safety of contractors and sub-contractors? - If yes provide a summary listing of procedures Page 4 of 5

5 HSE in Design Yes No Does the Consultant consider HSE aspects in the design stage of land development? Workplace Inspections Yes No Are regular health and safety audits and inspections at worksites undertaken? Is there a procedure by which employees/contractors can report hazards at workplaces? OH&S Performance Monitoring Yes No Is there a system for recording and analysing health and safety performance statistics including number and type of injuries and incidents? Are employees regularly provided with information on company health and safety performance? Regulatory Action Yes No Has the company ever been convicted of an occupational health, safety or environmental offence? Insurances Yes No Does the company have workers compensation insurance? Provide policy number and expiry date: Company Reference Provide the following information for the two (2) most recent contracts completed by the company Contract Description 1st Contract 2nd Contract Client Name of Client Contact Phone Number Client Contact No. of lost time injuries Total number of work hours on contract Total days lost due to injuries Page 5 of 5

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