Global Projects & Engineering

Contractor Safety Pre-Qualification Form

Contractor/Supplier/Seller SANESTO MG, S.R.L. Phone 809-481-5315
Name : & Email: info@sanestomg.com

Contractor/Supplier/Seller AV. SAN MARTIN #253 EDIF. SANTANITA I LOCAL 102

Address :

Project Location: BRASSERIE NATIONALE D’HAITI

Work area: Brewing/Packaging/Utilities/logistics/Engineering/Civils/Maintenance/Other (specify):

Instruction:
 The Contractor/Supplier/Seller must complete this form in English and provide suitable evidence as proof that
they meet the criteria
 Reference to the evidence documents must be stated in the Remarks Column
 Once all boxes are completed and suitable evidence is provided the Contractor/Supplier/Seller must complete
and sign the bottom row and then return the form to Heineken for approval
 If approved this Pre-qualification is valid for up to 3 years (subject to adequate safety performance)
 Note: Non-completion of this form or failure to follow the above instruction will delay approval to tender

Management = Leadership and commitment of contractor Yes No Remarks

1 Is there evidence of commitment towards Safety Management (e.g. Safety X
Policy, Safety Management System, OHSAS 18001 certification)?

Man = Safety organisation of contractor Yes No Remarks

1 Do the Contractor/Supplier/Seller supervisors have competences with X
respect to conducting the contract work including all safety requirements
(e.g. formal safety training, experience etc.)?
2 Do the Contractor/Supplier/Seller employees have competences with X
respect to the execution of the work including basic industrial safety skills
(general training) and knowledge about specific hazards arising out of the
nature of the activities (e.g. specialised training)?
3 Are Sub-Contractors selected based on competences, capability to meet X
the safety standards? (e.g. evidence of company pre-qualification
procedure)
4 Is there evidence that legal requirements are followed up adequately X
(registration, valid permits) and are good safety practices used?

Methods = Procedures by contractor Yes No Remarks

1 Does the Contractor/Supplier/Seller have written procedures describing in X
detail safe working practices related to the proposed activities? (please
provide)
2 Does the Contractor/Supplier/Seller ensure that equipment used on-site is X
correctly registered, inspected and maintained in a safe working condition?
(e.g. crane or equipment certification, test and inspection records)

Materials = Hazard management by contractor Yes No Remarks

1 What methods are used to identify, assess, control and mitigate hazards? X

Page | 1 of 2 Safety pre-Qualification: Contractor Safety Management

Internal safety procedure HMESC: 01.40.01.512 24 April 2018
 Global Projects & Engineering
Contractor Safety Pre-Qualification Form
(e.g. example of Risk assessment methodology)
2 Have the Contractor/Supplier/Seller employees been trained on the X
potential hazards of (dangerous) chemicals, noise, radiation, asbestos etc.
encountered in the course of their work? (e.g. safety training records)
3 Does the Contractor/Supplier/Seller have arrangements for the provision X
and maintenance of PPE and clothing, both standard and that is required
for specialised activities (e.g. internal procedure and/or inspection records)
4 Are contractor employees aware of the zero tolerance policy regarding X
drugs and alcohol use? (e.g. internal policy and/or training records)

Measurement = Performance monitoring by contractor Yes No Remarks

1 Has the Contractor/Supplier/Seller suffered from any statutory notifiable X
violations of (safety) law in the last 5 years?
2 Has the Contractor/Supplier/Seller suffered from any improvement X
requirement or prohibition notices by a relevant national body or have
they been prosecuted under any safety legislation?
3 Does the Contractor/Supplier/Seller maintain records of incidents and X
accidents (lost time injuries, fatalities)? Provide details over the last 5
years.
4 Do you consider your safety performance to be at a good level? X Always room for
improvement.

Additional comments:

Send evidence and completed form to: Heineken Global Projects & Engineering
Global Safety: Adam Sivell or Tjeert Rozema
Email: adam.sivell@heineken.com or tjeert.rozema@heineken.com
Conclusion Heineken Global Supply Chain Projects & Engineering:

: The Contractor/Supplier/Seller has been qualified for the minimum safety requirements of the work
: The Contractor/Supplier/Seller has not been qualified for safe execution of the work

Name: Date: Signature:

Heineken Global Safety

Contractor/Supplier/Seller (confirmation that May 16th,
the above statements are correct and provide a Roberto Modesto-Sasso 2018
fair reflection of their safety performance): SANESTO MG, S.R.L.

Page | 2 of 2 Safety pre-Qualification: Contractor Safety Management

Internal safety procedure HMESC: 01.40.01.512 24 April 2018