FM 0504-4
Contractor Management Pre-qualification WHS Questionnaire Category 1
Organisation Name: / Date:1 / Organisation Details
1a / List and describe the type of work/services to be provided by your organisation:
Identify all high risk construction work activities that your organisation will perform for the Port of Newcastle: Please tick more than one, if applicable.
Work that involves ariskofapersonfalling morethan 2metres. / ☐ / Work that is carried out on a telecommunication tower. / ☐ /
Work that involves demolition of an element of a structure that is load-bearing or otherwise related to the physical integrity of the structure. / ☐ / Work that is carried out on or near:
- pressurised gas distribution
mains or piping. - chemical, fuel or refrigerant lines.
- energised electrical installations
or services.
Work that involves structural alterations or repairs that require temporary support to prevent collapse / ☐ / Work that iscarriedout in anareathat mayhave acontaminatedor flammable atmosphere. / ☐ /
Work that is carried out in or near a confined space. / ☐ / Work that involves tilt-uporprecast concrete. / ☐ /
Work that involves theuseofexplosives / ☐ / Work that involves, or is likely to involve, the disturbance of asbestos. / ☐ /
Work that is carriedout in or nearashaftor trench with anexcavateddepthgreater than 1.5metres oriscarriedout in or nearatunnel. / ☐ / Work that is carried out on, in or adjacent to a road, railway, shipping lane or other traffic corridor that is in use by traffic other than pedestrians. / ☐ /
Work that iscarriedoutin anareaataworkplaceinwhich there is anymovement ofpowered mobile plant. / ☐ / Work that is carried out in an area in which there are artificial extremes of temperature. / ☐ /
Work that is carried out in or near water or other liquid that involves a risk of drowning / ☐ / Work that involves diving work
Note: All diving work at PON is considered high risk. / ☐ /
AnexampleSafe Work Method Statement (SWMS) for each work activity selected above must be provided.
1b / Specify the total number of workers currently employed within your organisation:
How many are permanent?
How many are casual?
2 / Work Health & Safety Management
Do you have a full time WHS Manager or Advisor? / Yes
☐ / No
☐
Name: / Title:
Email Address: / Telephone:
Qualifications:
3 / Work Health & Safety Performance
Please provide statistical evidence of your organisation's safety performance in the past 3 years
Timeline / Current YTD / Last Year / Previous Year to Last
Number of Lost Time Injuries
Lost Time Injury Frequency Rate
Number of Medical Treatment Injuries
Medical Treatment Injury Frequency Rate
Number of First Aid Injuries
Number of Near Miss Incidents
4 / Notifiable Incident / Dangerous Occurrences
4a / Has your organisation been convicted of any WHS offences in the past 3 years, or are there any proceedings underway or pending? / Yes
☐ / No
☐
If yes, provide details:
4b / Has your organisation received any Government regulatory agency (e.g. SafeWork NSW) notices in the past 3 years, i.e. improvement notices, prohibition notices, or penalty notices? / Yes
☐ / No
☐
If yes, provide details:
4c / Has your organisation reported any notifiable incidents to a Government regulatory agency (e.g. SafeWork NSW) in the past 3 years? / Yes
☐ / No
☐
If yes, provide details:
5 / Work Health & Safety Management System
5a / Do you have a documented Work Health & Safety (WHS) Management System?Please attach a copy of the contents page. / Yes
☐ / No
☐
5b / Is it accredited? Please attach a copy of the certificate.
(e.g. AS/NZS 4801, ISO-14001, ISO-18001, Australian Government Building and Construction WHS Accreditation Scheme, NSW Government WHS Management System and Auditing Guidelines - 5th Edition, etc.) / Yes
☐ / No
☐
If yes, specify:
6 / WHS Policy / Section in Manual
6a / Does the organisation have a WHS policy?
Please attach a copy. / Yes
☐ / No
☐
6b / Is the WHS Policy signed by the Chief Executive Officer or equivalent? / Yes
☐ / No
☐
6c / Is it appropriate to the nature and scale of the organisations WHS risks? / Yes
☐ / No
☐
6d / Does it demonstrate a commitment to establish measurable objectives and targets to ensure continued improvement aimed at eliminating work-related injury and illness? / Yes
☐ / No
☐
6e / Does itinclude a commitment to comply with relevant WHS legislation and other requirements to which the organisation subscribes? / Yes
☐ / No
☐
6f / Is it documented, implemented, communicated to all employees and maintained? Please provide evidence. / Yes
☐ / No
☐
6g / Is it reviewed periodically? / Yes
☐ / No
☐
7 / Risk Management / Section in Manual
7a / Does the organisation have a Risk Management Procedure? Please attach a copy. / Yes
☐ / No
☐
7b / Does the Risk Management Procedure ensure the following are conducted?
A) hazard identification;
B) hazard/risk assessment;
C) control of hazards/risks; and then
D) evaluation of steps A to C? / Yes
☐ / No
☐
7c / Does the organisation have a risk assessment specific to the project or work/services provided?
Mandatory for high risk activities.
Please attach a copy of an example. / Yes
☐ / No
☐
7d / Does the organisation have safe work method statements (SWMS) specific to the high risk construction work tasks to be undertaken?
Mandatory for all high risk construction work activities.
Please attach a copy of an example. / Yes
☐ / No
☐
7e / Do the SWMS’sidentify the specific hazards and risks related to the high risk construction work (HRCW)? / Yes
☐ / No
☐
7f / Do the SWMS’s describe the measures to be implemented to control the risks using the Hierarchy of Controls to determine the most appropriate control to reduce the risks where reasonably practicable? / Yes
☐ / No
☐
7g / Do the SWMS’s controls include clear directions? / Yes
☐ / No
☐
7h / Do the SWMS’s identify that they have been developed in consultation with workers and their health and safety representatives (if any)? / Yes
☐ / No
☐
8 / Legal Compliance / Section in Manual
8a / Does the organisation have a procedure to identify and access all applicable legal and other requirements that are directly applicable to WHS issues related to its activities? e.g. WHS Legislation, codes of practice, Australian Standards?
Please attach a copy. / Yes
☐ / No
☐
8b / Does the organisation subscribe to receive regular WHS legislative updates?
Please attach a copy. / Yes
☐ / No
☐
8c / Does the organisation have legal register that identifies the legislation that is a minimum for compliance and defines the method of compliance, records produced and the means of measuring and monitoring compliance?
Please attach a copy. / Yes
☐ / No
☐
8d / Does the organisation communicate relevant information on legal and other requirements to its employees? / Yes
☐ / No
☐
9 / Training & Competency / Section in Manual
9a / Does the organisation have aTraining & Competency procedure?
Please attach a copy. / Yes
☐ / No
☐
9b / Does the organisation have a WHS Induction Program for workers? / Yes
☐ / No
☐
9c / Does the organisation provide a WHS Training Program for supervisors? / Yes
☐ / No
☐
9d / Does the organisation ensure that employee licences, training and competencies are current and that records are maintained? (e.g. drivers licence, qualifications,first aid, high risk work licences, confined space etc.)
Please attach a copy of an example. / Yes
☐ / No
☐
9e / Does the organisation maintain records of on-going/on the job training? e.g. tool box meetings conducted, specialist training etc.
Please attach a copy of an example. / Yes
☐ / No
☐
9f / Does the organisation have programmes in place for the re-assessment / re-training of personnel? / Yes
☐ / No
☐
9g / Identify all work activities that your organisation will perform for the Port of Newcastle that requires a high risk work licence: Please tick more than one, if applicable.
Crane operations / ☐ / Hoists / ☐ /
Dogging or rigging / ☐ / Pressure equipment operations / ☐ /
Scaffolding / ☐ / Reach stackers / ☐ /
Forklift operations / ☐ /
Please attach a copyof the relevant licences as an example.
10 / Consultation and Communication / Section in Manual
10a / Does the organisation have aWHS consultation procedure? Please attach a copy. / Yes
☐ / No
☐
10b / Does the procedure allow for consultation with:
•Workers e.g. Health & Safety Representatives (HSR’s)
• Co-operation and co-ordination with other PCBU’s / Yes
☐ / No
☐
10c / Does the organisation have Health & Safety meeting schedules, agendas, minutes, and toolbox talk meetings?
Please attach a copy of an example of each. / Yes
☐ / No
☐
10d / Are workers involved/consulted/informed in decision making over WHS matters?
Please attach a copy of an example. / Yes
☐ / No
☐
10e / Can the organisation provide evidence of workers involvement in inspections and incident investigations?
Please attach a copy of an example. / Yes
☐ / No
☐
10f / Does the organisation have a list of worker health and safety representatives (HSR’s) and or committee members?
Please attach a copy. / Yes
☐ / No
☐
10g / Does the organisation have a procedure for communication and dissemination of information?
Please attach a copy. / Yes
☐ / No
☐
11 / Document & Data Control / Section in Manual
11a / Is there a procedure for Document & Data Control?
Please attach a copy. / Yes
☐ / No
☐
11b / Can documents be easily located? / Yes
☐ / No
☐
11c / Are documents reviewed periodically? / Yes
☐ / No
☐
11d / Are current versions accessible at all locations? / Yes
☐ / No
☐
11e / Are obsolete documents and data promptly removed? / Yes
☐ / No
☐
12 / Emergency Preparedness & Response / Section in Manual
12a / Does the organisation have an emergency preparedness and response procedure/plan that covers work site specific emergency arrangements?
Please attach a copy of an example. / Yes
☐ / No
☐
12b / Has the organisation completed an emergency evacuation drill in the past year?
Please attach a copy of the most recent debrief records following a drill. / Yes
☐ / No
☐
12c / Are employees trained in emergency preparedness and procedures?
Please attach a copy of an example training record. / Yes
☐ / No
☐
12d / Can the organisation demonstrate that they provide visitors/subcontractors who visit their site with specific information on site safety hazards including emergency evacuations?
Please attach a copy of an example. / Yes
☐ / No
☐
13 / Measuring, Monitoring & Review / Section in Manual
13a / Is there a procedure for conducting WHS internal audits? Please attach a copy. / Yes
☐ / No
☐
13b / Are the WHS audits at regular/programmed intervals? / Yes
☐ / No
☐
13c / Has the organisation specified a minimum competency level for personnel undertaking audits? / Yes
☐ / No
☐
13d / Is there evidence of an audit? e.g. reports
Please attach a copy of an example. / Yes
☐ / No
☐
13e / Does the organisation have processes in place to review, action and close non-conformances / audit findings? / Yes
☐ / No
☐
13f / Is there a procedure for conducting workplace inspections?
Please attach a copy. / Yes
☐ / No
☐
13g / Are WHS inspections conducted in your organisation and at work sites? / Yes
☐ / No
☐
13h / Are plant/equipment inspections conducted in your organisation and at worksites?
Please attach a copy of an example. / Yes
☐ / No
☐
13i / Does your organisation use pre-start checks?
Please attach a copy of an example. / Yes
☐ / No
☐
14 / Incident Reporting & Investigation / Section in Manual
14a / Is there a procedure for reporting and investigating incidents, hazards and near misses?
Please attach a copy. / Yes
☐ / No
☐
14b / Is there an incident report and investigation form?
Please attach a copy. / Yes
☐ / No
☐
14c / Does the incident reporting and investigation procedure include the requirement to notify the regulator and PoN of notifiable incidents; and PoN of all incidents immediately? / Yes
☐ / No
☐
14d / Evidence of completed investigation forms?
Please attach a copy of an example. / Yes
☐ / No
☐
14e / Is there a procedure for follow up actions resulting from incidents?
Please attach a copy. / Yes
☐ / No
☐
15 / Records Management / Section in Manual
15a / Is there a procedure for Records Management?
Please attach a copy. / Yes
☐ / No
☐
15b / Are WHS records legible, identifiable and traceable to the activity or service involved? / Yes
☐ / No
☐
15c / Are archival documents and data retained for legal or knowledge preservation? / Yes
☐ / No
☐
15d / Are retention times established and recorded? / Yes
☐ / No
☐
16 / Injury Management / Section in Manual
16a / Is there a procedure for Injury Management and Return to Work?
Please attach a copy. / Yes
☐ / No
☐
16b / Is the Injury Management and Return to Work Procedure communicated to employees?
Please attach a copy of an example. / Yes
☐ / No
☐
16c / Do you have a procedure to ensure that injured employees have suitable alternate duties available?
If yes provide details. / Yes
☐ / No
☐
16d / Does your organisation have a trainedReturn To Work Co-ordinator to manage injured employees?
Please attach a copy of the training certificate. / Yes
☐ / No
☐
16e / Does your organisation have a nominated rehabilitation provider?
Please provide the name of the provider. / Yes
☐ / No
☐
17 / Managing Subcontractors / Section in Manual
17a / Does your organisation engage subcontractors? / Yes
☐ / No
☐ / If no go to the declaration.
List the subcontractors used by your organisation and describe the type of work/services that they provide:
17b / Is there a procedure for managing subcontractors?
Please attach a copy. / Yes
☐ / No
☐
17c / Does your organisation provide induction training for all subcontractors? / Yes
☐ / No
☐
17d / Can you provide evidence of induction training for subcontractors? i.e. copy of an induction training record within the last 12 months.
Please attach a copy. / Yes
☐ / No
☐
17e / Is there a system for reviewing subcontractors' WHS site specific safety plans/risk assessments and safe work method statements? Evidence may include:
-WHS site safety plan/risk assessments and or SWMS review form.
-Records of toolbox meetings
Please attach a copy of an example. / Yes
☐ / No
☐
17f / Does your organisation ensure that subcontractors regularly check and maintain all plant and equipment used on site?
Please attach a copy of an example. / Yes
☐ / No
☐
17g / Is there a system for subcontractors to report hazards, incidents, non-compliance issues or complaints?
Please attach a copy of an example. / Yes
☐ / No
☐
17h / Does your organisation conduct regular reviews of subcontractor works and working practices?
Please attach a copy of an example. / Yes
☐ / No
☐
17i / Does your organisation advise subcontractors of any identified hazards, i.e. WHS issues?
Please attach a copy of an example. / Yes
☐ / No
☐
18 / Declaration
I hereby certify that answers provided on this Questionnaire and any attachments to be correct and open to review by Port of Newcastle, or its Authorised Agents.
Name:
Position Title:
Telephone:
Email:
Date:
Signature:
Revision C22 March 2016 Page 1 of 8