Health and Safety Pre-Qualification Application Self-employed/Small businesses and Consultants (less than five employees) 1. Business Information Company name: Address: Phone: Mobile: Email address: Number of employees: 2. Key Personnel Name of person in charge of health and safety: Position Held: Phone: Mobile: Email address: 3. Insurance Does the company carry any of the following insurances? (You may be asked for extra cover for specific work) Public liability insurance Third party insurance Contractor all risk insurance Professional Indemnity Insurance (Please enclose copies of proof of insurance) October 2015 1 of 5
4. Type of work Please advise the area(s) of Tasman District Council you expect to work for (tick all that are applicable) Environment and Planning Corporate Services Community Development Engineering Services Name of the contact person you have at Council (if known) Please describe the type(s) of work this application covers: 5. Health and Safety Management Do you have written emergency procedures? Yes No Is appropriate Personal Protective Equipment (PPE) available and used? Yes No Do you write a safety plan and identify risks prior to starting a job? Please supply three previously completed copies Do you engage sub-contractors? (if yes, please describe how you manage them) Yes Yes No No Do you induct workers and others that enter your worksite/place? Yes No Do you have a hazard register that identifies risks associated with the work you do? Yes No Do you have a procedure for the reporting, recording, investigation and follow up of serious harm accidents, incidents or occupational illnesses? Have you had any improvement or prohibition notices issued by WorkSafe in the past 5 years? Yes Yes No No Have you been prosecuted by WorkSafe in the past 5 years? Yes No 6. Hazardous Substances Do you have safety data sheets for hazardous substances? Yes No NA Do you have approved handlers for hazardous substances? Yes No NA Are there written procedures for handling and storing hazardous substances? (If yes, please enclose a copy) Yes No NA
7. Plant and Equipment Do you electrically test and tag electrical appliances and tools that you would be using on Council assets and worksites? Yes No NA Do you have procedures for maintaining plant, equipment and vehicles? Yes No NA 8. Competency and compliance Please supply evidence of training and or qualifications/certification / trade qualifications relevant to the work you may do for Council. Examples: Confined space entry, height safety training, electrical certificate, NZQA unit standards, chainsaw cert, first aid, approved handler, vehicle licenses (WTR) Trade qualifications for electrical registration, gas fitter license, arborist. Do you hold ACC s WSD (Work Safety Discounts) certificate? If yes, please attach a copy Yes No Please list names of any Trade or Employers Associations that you are a member of, or if you are prequalified by SiteWise: 9. Contractor Signature I understand I may be required to provide additional information to support my application. I understand information provided on this form will be collected and held by the Health & Safety Advisor. I certify that to the best of my knowledge the information given above is correct. Name: Position: Signature: Date: October 2015 Page 3 of 5 SME application
Contractors Health and Safety Agreement Policy It is the policy of Tasman District Council s to engage only competent Contractors who shall meet stringent health and safety standards and checks. The Council expects and will ensure that, so far as is reasonably practicable, all Contractors, Sub-contractors and their employees, comply with all relevant safety legislation, approved codes of practice and industry standards. Contractors will: Comply with and understand their obligations to themselves, their sub-contractors and their employees under current Health and Safety in Employment Act 1992 (including amendments) and any other relevant legislation including rules and regulations of the Council. Notify the Council of any hazards they bring on to, create or are aware of on site. Be inducted before commencing work on any site and will agree to our health and safety policies and procedures. Have an effective health and safety management system in place which includes methods for identifying any significant hazards. Any signification hazards are to be reported to the Council as soon as practicable and advised in writing within seven days. Ensure all Contractor employees and any sub-contractors they engage, are suitably qualified, experienced, trained and supervised and all required certificates are current. Have procedures in place for dealing with emergencies that may arise while employees are at work. The Contractor is to ensure their employees, sub-contractor employees and the Council Engaging Supervisor are familiar with these procedures. If requested, provide the Council with any documents relating to health and safety in relation with this contract for inspection. Lodge Notifiable Works in writing to WorkSafe at least 24 hours before carrying out the work in accordance with S26 Health and Safety in Employment Regulations 1995. A copy will be given to Tasman District Council Engaging Supervisor. Accidents and near misses are to be reported to the Council Engaging Supervisor and Council Health and Safety Advisor within 48 hours or as required in contract documentation or agreement with the Council Engaging Supervisor. Advise the Council Engaging Supervisor and/or the Council Health & Safety Advisor verbally within an hour and in writing within 48 hours of all serious harm events and advise WorkSafe as soon as possible by phone and provide a written notice of the circumstances within 7 days. Provide and maintain adequate first aid facilities, treatment register, supplies and qualified first-aiders. Provide their employees with Personal Protective Equipment (PPE) that may be required to complete the work safely. Advise the Tasman District Council of any changes in procedures, standards, and performance or key personnel as they occur. Tasman District Council will: Monitor the Contractor s activities and carry out safety audits periodically during the progress of the contract. Suspend work at the Contractor s expense where the Council is not satisfied that all practicable steps are being taken to ensure the health and safety of employees and others in connection with the contract. Where repeated serious breaches of contract are identified, the Tasman District Council shall have the discretion to terminate the contract. Declaration By signing below the Contractor agrees: That I have read and understood the Contractors Health and Safety Agreement (above) That I have read and understood the Contractors Health and Safety Information Booklet To abide by all health and safety requirements detailed in these documents I confirm my acceptance of this agreement by returning the following documents to the Health and Safety Advisor, Tasman District Council to enable my application to be reviewed:
Tick to confirm these documents are included with your application Completed Health and Safety Pre-Qualification Form Signed Contractors Health and Safety Agreement Copies of current insurance certificates Copies of 3 previously completed Safety Plans Copy of written procedures for handling and storing hazardous substances (if applicable) Copies of evidence of training / qualifications / certifications / Trade Certifications relevant to the work you may do for Council Copy of your ACC WSD certificate (if applicable) Signed for and on behalf of the Contractor Full name: Signed for and on behalf of Tasman District Council Full name: Signature: Signature: Position: Position: Date: Date: H&S Approved contractor status shall remain current for two years subject to the Contractor s health and safety performance. October 2015 Page 5 of 5 SME application