HSEF1101.

3 Contractor HSE Questionnaire

Health, Safety and Environment Form Approved by: Manager Sustainability & Safety Form Revision: 0 Date: 14st Feb 2013 Page 1 of 4

Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as long as the intent of the form is not compromised.

HSEF1101.3 Contractor HSE Questionnaire

This form is completed by the contractor / supplier representative when requested by Hydro Tasmania. The information provided is used to evaluate the HSE management of the contractor / supplier company. The completed form is retained on file by the Hydro Tasmania Representative.
CONTRACTING COMPANY DETAILS Company name:

Company address:

Phone:

Information provided by (name): Signature: Services offered:

Role: Date:

CONTRACTOR HSE MANAGEMENT ASSESSMENT Contractor to answer and provide comment. Where relevant, summary supporting evidence should be attached or contact details provided for persons who can provide more details information. Hydro Tasmania will complete the Rating section. Hydro rating

HSE Management Requirement

1. Policy and management

Yes

No

Comments

1.1 Does your business have a WH&S and/or Environmental management system audited by a recognised independent authority? If only safety certification is held, proceed directly to section 5 of this form. If environmental certification is held, skip section 5 of this form. If both safety and environmental certification are held, proceed directly to section 6 of this form 1.2 Does your business have a health and safety policy? If yes provide a signed and dated copy of policy. 1.3 Does your business have an environmental policy? If yes provide a signed and dated copy of policy. 1.4 Is there a business WH&S management system manual or plan? If yes provide a copy of contents page(s).

Date printed 08/03/2014

HSEF1101.3 Contractor HSE Questionnaire

Health, Safety and Environment Form Approved by: Manager Sustainability & Safety Form Revision: 0 Date: 14st Feb 2013 Page 2 of 4

Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as long as the intent of the form is not compromised.

HSE Management Requirement 1.5 Is there a business environmental management system manual or plan? If yes provide a copy of contents page(s). 1.6 Are health and safety and environmental responsibilities clearly identified for all levels of staff? If yes provide details. 1.7 Are health, safety and environmental inductions and training conducted in your business? If yes, provide contact details for the person responsible for arranging this training. 1.8 Are records maintained of all HSE training and induction programs undertaken in your business? If yes, provide copies of relevant training matrices.
2. Safe work practices and procedures

Yes

No

Comments

Hydro rating

2.1 Has the company prepared safe operating procedures or specific safety instructions relevant to its operations? If yes, provide a summary listing of procedures or instructions. 2.2 Does the business have all required health and safety permits and approvals in relation to the proposed work? If yes, provide a summary listing of permits. 2.3 Are there procedures for maintaining, inspecting and assessing the hazards of plant operated/owned by the business? If yes, provide a list of the procedures. 2.4 Are there procedures for storing and handling hazardous substances? If yes, provide a list of the procedures. 2.5 Are there procedures for identifying, assessing and controlling risks associated with manual handling? If yes, provide a list of the procedures. 2.6 Is there an established process for the preparation of job hazard analyses/ safe work method statements? If yes, provide details and an example.
3. Health and safety workplace inspection

3.1 Are regular health and safety inspections at workplaces undertaken? If yes, provide details. 3.2 Are standard workplace inspection checklists used to conduct health and safety inspections? If yes, provide details or examples.

Date printed 08/03/2014

HSEF1101.3 Contractor HSE Questionnaire

Health, Safety and Environment Form Approved by: Manager Sustainability & Safety Form Revision: 0 Date: 14st Feb 2013 Page 3 of 4

Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as long as the intent of the form is not compromised.

HSE Management Requirement 3.3 Is there a procedure by which employees can report hazards at workplaces? If yes, provide details.
4. Health and safety consultation

Yes

No

Comments

Hydro rating

4.1 Is there a workplace health and safety committee? If no, provide a brief explanation. 4.2 Do you hold work group meetings related to WH&S matters? If yes, please provide details. 4.3 Are there employee-elected health and safety representatives?
5. Environmental practices and procedures

5.1 Has the company identified the environmental aspects and impacts relevant to its operations? If yes, provide a summary listing or register. 5.2 Is the business aware of, or has it developed processes for, the management of aboriginal and historic cultural heritage? If yes, provide details (e.g. heritage management plans) 5.2 Does the business have all required legal and environmental permits and approvals in relation to the proposed work? If yes, provide a summary listing of permits. 5.3 Are there procedures for disposing of wastes, including controlled substances? If yes, provide details. 5.4 Is there an established process for the preparation of environmental impact assessments and management plans? If yes, provide detail.
6. HSE performance monitoring

6.1 Is there a documented incident reporting and investigation process? If yes, provide a copy of a standard incident report form. 6.2 Has the business ever been convicted of an workplace health and safety or environmental offence? If yes, provide detail. 6.3 Does the business audit its health, safety and environmental performance? If yes, provide detail and an example audit report

Date printed 08/03/2014

HSEF1101.3 Contractor HSE Questionnaire

Health, Safety and Environment Form Approved by: Manager Sustainability & Safety Form Revision: 0 Date: 14st Feb 2013 Page 4 of 4

Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as long as the intent of the form is not compromised.

HSE Management Requirement 6.4 Is there a system for recording and analysing health, safety and environmental performance statistics? If yes, provide the following: What are the number of workplace: Fatalities Lost time injuries Medically treated injuries Reportable safety incidents Reportable environmental incidents Fines or prosecutions
7. References

Yes

No

Comments

Hydro rating

Last reporting year

1 year previous

2 years previous

7.1 Provide at least three written references, or contact details for referees, for work or a similar nature or similar contract value to that proposed. 7.2 Provide copies of one safety and/or environmental management plan developed and implemented by the business for work of a similar nature.

HYDRO TASMANIA - EVALUATION RATING TABLE ASSESSOR Name: RATING F = Fail, does not meet Hydro Tasmanias required standards P = Pass, meets or exceeds Hydro Tasmanias required standards

Role:

Signature:

Date:

Date printed 08/03/2014