HSE-Contractor Prequalification

Questionnaire
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Date : Page:

Contractor Name : Keller Franki

Address :

In general your firm’s Health, Safety & Environment (HSE) performance for the last 3 years
will considered for this qualification evaluation with emphasis given to the most recent year’s
performance.

Provide the following related HSE performance

HSE STATISTIC RECORD

No Item Year to Date Year2017 Year2016 Year2015
1 Man Hour 410.674 424.572 520.655 600.000
2 Man day
3 Number of injury incident without lost work day 0 0 0 1
4 Number of light injury incident 0 0 0 2
5 Total number of lost work day 0 0 0 74
6 Number of Fatality Incident 0 0 0 0
7 Number of Near Miss case 11 0 0 0
8 Number of First Aid case 2 1 1 1
Please provide details of each of the recordable injuries (if applies)
No Date Details of incident Treatments received Investigation outcome
1
2
3
SAFETY MANAGEMENT SYSTEM & POLICY
No Item Yes No Remark
1 Does your company have a policy of HSE? √ If yes, please
attach
2 √ If yes, please
Is the HSE policy was socialized and understood by all workers? attach program
of socialized
3 Is the HSE policy signed by top corporate leaders? √
4 Is the HSE Policy periodically/update as internal and external in √ If yes, please
conditions of company? attach a evident
5 Does your company have an organization of HSE? √ If yes, please
attach complete
with job desc.
6 Does your company have a management inspection program of √ If yes, attach the
HSE programs plan
7 Do the findings of the HSE management inspections are always √ If yes, attach the
follow up? evident
8 Is your company organizes regular meetings about HSE? √ If yes, attach the
evident
9 Does your company have a program HSE campaign? √ If yes, attach the
evident
10 Does your company have a training program HSE? √ If yes, attach the
program
11 Does your company have a HSE Induction program for all √ If yes, attach the
 HSE-Contractor Prequalification
Questionnaire
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worker & staff (including subcontractor)? evident

12 Does your company have a training of first aid? √ If yes, attach the
evident
13 Does your company conduct medical check-up on prospective √ If yes, attach the
employees who will be recruited? evident
14 Does your company conduct medical check-up of workers on a √ If yes, attach the
regular basis? evident
PROCEDURE
No Item Yes No Remark
1 Does your company have a procedure of emergency respond √ If yes, attach
plan? this procedure
2 Does your company have a procedure a training of emergency √ If yes, attach the
drill? evident
3 Does your company have a procedure first aid? √ If yes, attach
this procedure
4 Does your company have a procedure HSE Investigation Report √ If yes, attach
this procedure
5 Does your company have a procedure standard operation of tools √ If yes, attach
and heavy equipment? this procedure
6 Does your company have a procedure for handling, transferring √ If yes, attach
& storage hazardous substances materials? this procedure
7 Does your company have a procedure waste management? √ If yes, attach
this procedure
8 Does your company have a procedure prevention of traffic √ If yes, attach
accidents? this procedure
9 Does your company have a procedure for the ban on smoking, √ If yes, attach
drugs & alcohol? this procedure
10 Does your have a procedure implementation of PPE standard √ If yes, attach
this procedure
Does your company a have system operational procedure
following below are:
.a Permit to work system procedure √ If yes, attach
this procedure
.b Fall protection procedure √ If yes, attach
this procedure
.c Perimeter guarding/wall and roof openings procedure √ If yes, attach
this procedure
.d Mobile equipment safety procedure √ If yes, attach
this procedure
11 .e Fire protection procedure √ If yes, attach
this procedure
.f Medical treatment procedure √ If yes, attach
this procedure
.g Emergencies situation plan procedure √ If yes, attach
this procedure
.h Hazardous substances handling procedure √ If yes, attach
this procedure
.i Waste management procedure √ If yes, attach
this procedure
.j Excavation procedure √ If yes, attach
 HSE-Contractor Prequalification
Questionnaire
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this procedure
.k Electrical safety procedure √ If yes, attach
this procedure
.l Lifting procedure √ If yes, attach
this procedure
.m Hot work procedure √ If yes, attach
this procedure
.n Confined space entry procedure √ If yes, attach
this procedure
.o Lock out tag out (LOTO) procedure √ If yes, attach
this procedure
EQUIPMENT
No Item Yes No Remark
1 Does your company always to do check and certify all of the √ If yes, attach the
tools operate? evident
2 Does your company using heavy equipment equipped with √ If yes, attach the
certification of equipment that issued by institute of government evident
(Depnaker)
3 All operator of heavy equipment is expert and hold a certified of √ If yes, attach the
operation permit (Surat Ijin Operator) that issued authority by evident
government institute (Depnaker)
4 Does your company have a Personal Protective Equipment √ If yes, attach the
(PPE)? evident
5 Does your company always provides a complete personal √ If yes, attach the
protective equipment and suitable to be used to carry out the evident
work?
6 Does your company given enforcing sanctions for workers who √ If yes, attach the
do not use personal protective equipment? evident
HSE PROGRAM
Implementation of Personal Protective Equipment
a Head Protection √
b Eye Protection √
c Hearing Protection √
1
d Foot Protection √
e Respiratory Protection √
f Chemical Clothing Protection √
g Fall Arrest Protection √
2 Does your company have a HSE Manual Plan? √ If yes, attach the
doc.
3 Does your company hold workplace HSE Meeting for √ If yes, attach the
Supervisor? attendance list
4 Does your company hold Toolbox Meeting for worker? √ If yes, attach the
attendance list
5 Does your company pre-task planning HSE meeting with √ If yes, attach the
employees? attendance list
6 Does your company conduct HSE Inspection? √
7 Does your company implement of HSE Reward & Punishment √
for workers?
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Questionnaire
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Have your company performed work at any Bayer perimeter before?

YES….. NO…….
If yes, please describe what work have done and where the location of BAYER
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We understand that the information will be verified and any false information will result in
the company being disqualified of rejected for performing work for BAYER PROJECT. If
any information is false after the award of a contract will be terminated.

Completed By: ………

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…………………………………….
Signature

Phone number: …………………………..