Enterprise Exemplary Award 2018

“RecognizingbizSAFE Level Star Enterprises for their exemplary Workplace Safety and Health (WSH) performance and standards.”

Name of Organisation:

Application Submission Checklist

Item / Tick Here / Official Use
Part 1A:Eligibility Checklist
Part 1B:General Information
Part 2:Risk Management (RM) 2.0
Part 3:Risk Management Implementation
Part 4A:General Information on bizSAFE Champion
Part 4B:Write up by bizSAFE Champion
USB drive containing Application Form and ALL supporting documents

Management Endorsement of Application

I affirm that all statements and information given by my company and I in this application are true and correct to the best of my knowledge. I further affirm that I have not withheld/ misrepresented any material facts. I understand that if I make any false or misleading statement in this form, I may be disqualified from the bizSAFE Awards.
Name
Designation
Contact Number / DID: / Mobile:
Email Address
Signature of Management: / Date:

Part 1A:Eligibility Checklist

Note:Please do not apply if any of the answer below is “No”

No / Item / Yes/ No
1 / Is your organisation an SME (refer to Guideline)?
2 / Is your organization a bizSAFE Level Star Enterprise?
3 / NO fatality between 14 June 2016 and 13 June 2017?
4 / NO Dangerous Occurrence case between 14 June 2016 and 13 June 2017?
5 / NO Stop Work Order between 14 June 2016 and 13 June 2017?
6 / NOT under the Business Under Surveillance (BUS) programme between 14 June 2016 and 13 June 2017?

Part 1B:General Information

Particulars of Organisation
Name of Organisation as per ACRA / UEN record
ACRA No. / UEN
Mailing Address
Tel No.
Email Address
Nature of Industry
Company / Group employment size

including subsidiaries or associate company of a holding/parent organization
including temporary & part-time

/ Please list down the subsidiary company names etc., if any.
Company / Group Sales Turnover for FY2016 / S$
Between 14 June 2016
and 13 June 2017 / No. of reportable accident
No. of permanent disability case
Particulars of Contact Person
Name
Designation
Contact Number / DID: / Mobile:
Email Address

Part 2:Risk Management (RM) 2.0

Topic / For applicant’s input / Official Use
1.Holistic RM:
Human and Cultural Factors
Does your RM considers individual, job, organisational and environmental factors which can affect safety and health?

Show that safety critical tasks are prioritized;

Illustrate how these factors are of relevance to work activities.

/ (within 250 words)
2. Pragmatic RM
How does your organisation ensure that risk controls are effectively implemented on ground?
How does your organisation ensure that employees understand the hazards involved and the control measures to be taken to minimise the risk? / (within 250 words)
3. Upstream Risk Controls
How has your organisation implemented upstream risk controls (via elimination, substitution or engineering control) in your work activities?
Show such upstream risk controls which significantly reduce the risk. Such controls should not be measures stipulated in the WSH Act’s subsidiary legislation. / (within 250 words)

Part 3:Risk Management (RM) Implementation

Summary Score Sheet
No / Topic / Max Score / Self Score / Auditor Score / Official Use
3.1 / WSH Policy and Governance / 5
3.2 / RM / 16
3.3 / Safe Work Procedure (SWP) / 5
3.4 / RM Team / 4
3.5 / In-house WSH Rules / 5
3.6 / Inspection / 7
3.7 / Preventive Maintenance / 4
3.8 / Training / 6
3.9 / Reporting and Investigation / 8
3.10 / Total WSH and Others / 6
3.11 / Emergency Preparedness / 5
Total / 71
Score / 100%

Questionnaire for Risk Management Implementation:

Declaration by Assessor

I hereby declare that I:

have conducted an on-site assessment of the workplace and the assessments given are in accordance with the evidence given in the USB drive and what I observed during the assessment;

haveconducted an interview with selected employee(s) of the Applicant. The excerpts and conclusion are given are in accordance with responses given by the interviewees at time of interview;

will not directly or indirectly disclose or make available any information, in whole or in part, given to me by the applicant, to any other person or party, except submitting them to the WSH Council; and

will not make any duplicate copy of the USB drive or copy its contents without the consent of the Applicant.

Name of Assessor
Name of Organisation
Contact Number / DID: / Mobile:
Email Address
Date & Time of Assessment
Signature of Assessor: / Date:

Part 4A:General Information on bizSAFE Champion

Particularsof Nominee
Name
Designation
NRIC / FIN No.
Date of Birth
Contact Number / DID: / Mobile:
Email Address
Date Joined company
Job Description in company
WSH courses & workshops attended
(To be supported by documentary evidence)
Name of course or workshop / Organiser or Training Provider / Course Date
e.g. bizSAFE Level 2, etc.

Part 4B:Write-up by bizSAFE Champion

Assessment for bizSAFE Champion Award
Question / For nominee’s input / Official Use
In your opinion, what qualities makes a bizSAFE Champion? / (within 250 words)
You may consider your role and contribution in:

implementing Risk Management for your organisation;
encouraging WSH participation and involvement efforts in the organisation;
creating awareness for bizSAFE programmewithin the organization;
Achieving / contributing beyond your responsibilities as an employee of an organisation.

Why do you think you meet these qualities? / (within 250 words)

Declaration by Nominee

I affirm that all statements and information given by me in this form are true and correct to the best of my knowledge. I further affirm that I have not withheld/ misrepresented any material facts. I understand that if I make any false or misleading statement in this form, I may be disqualified from the bizSAFE Awards
Signature of Nominee: / Date:

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