/ Approved by:
Risk Manager / Issue:
06 / December 2015
Form: 10.2A / Contractors Compliance Assessment
CONTRACTOR
SAFETY, HEALTH, ENVIRONMENTAL AND QUALITY COMPLIANCE
Name of Company / Organisation:
Type of Business:
Address:
Phone Number
Name of H&S Representative
Position of H&S Representative:
email:
Date:

Completing this Questionnaire

This questionnaire is designed to allow for an assessment of your company’s Safety, Quality and Environmental Management Systems level and performance

All relevant sections must be completed fully, and if no action or work has been taken in respect of any question or section an explanation of this may be required to be followed up with you.

Each reply will be assessed on the grounds of the guidelines.

Circle YES or NO

Health and Safety Management Systems performance
Supply an overview of your organisations Health and Safety Management in the following areas.
2014 / 2015 / 2016
a. Number of Serious Harm accidents
b. Number of Lost Time Injuries
c. Number of Lost time days through injury
d. Number of Improvement Notices issued
e. Number of Prohibition Notices issued
f. Number of Prosecution Notices issued
PART A
Health & Safety Management
Health and Safety Management Systems
Please Supply Copies of all evidence, including reports
Q1 / Is your organisation part of the ACC WSMP / WSD or Partnership Programme? / YES NO
Primary Secondary Tertiary
Q2a / Is your organisation accredited to NZS 4801 (or similar)? / YESNO
Q2b / Do you have an appropriate health & safety system in place? / YESNO
Q3 / Does your organisation have QEST certification or similar? / YES NO
Q4 / Does your organisation have appropriate works insurance? / YES NO
If your answer to Q1 or Q2 above is YES - attach a copy of your certification move to Section B.
If your answer to Q3 above is YES - attach a copy of your current certification; your current Hazard Register (with controls) and relevant training records then move onto Section B.
If your answers to Q1- Q3 were NO - continue with the rest of this section

Health and Safety Management - Capability

Standards
Do you have a written Health and Safety Management System?
/ YES NO
Management Commitment
Do you have a written Health and Safety Policy or statement of intent?
Please supply a Copy / YES NO
Have you clearly defined Management responsibilities? / YES NO
Do you regularly review Health and Safety performance?
/ YES NO
How do you achieve this and when was it last completed?
Hazard Management
Do you have a Hazard Register?
/ YES NO
Have you Risk assessed all Significant Hazards? / YES NO
Have you applied control measures to each hazard? / YES NO
Do you regularly assess hazards? / YES NO
Have you provided your staff with a copy of your hazards and control measures / YES NO
Training and Supervision
Have you documented evidence of training provided and relevant qualifications and work experience? / YES NO
Are all staff who are not adequately trained or experienced to undertake work in a safe manner supervised by an experienced worker? / YES NO
Have all staff been fully trained in all safety equipment, plant and chemicals they use? / YES NO
Do you have a training plan in relation to your identified hazards? / YES NO
Who undertakes this training?
Accidents / Injuries in the Workplace
Do you maintain a register of all accidents, near misses and serious harms? / YES NO
Do you have a procedure for the investigation of accidents/incidents?
/ YES NO
Who is responsible for this?
/ YES NO
Do you have an appointed safety officer/s for site work?
/ YES NO
Has this person been through a recognised safety course? / YES NO
Are investigations recorded in writing?
/ YES NO
Who reviews these investigations?
Emergency Procedures

Do you have a plan for all likely emergencies?

/ YES NO
Does your plan allocate specific responsibilities to individual staff
/ YES NO
Do you have training in relation to emergency plans?
/ YES NO
Do you have current First Aid / CPR trained staff? / YES NO
Sub-Contractors

Do you set a standard for your sub contractors?

/ YES NO

Do you monitor the performance/non-conformance of your sub-contractors?

/ YES NO
Who is the person who is responsible for contractor safety in your organisation?
Have there been any serious accidents, to any of your staff or persons on your work site/s in the past 2 years?
/ YES NO
If YES, please attach details
Have you ever been served with an Improvement or Prohibition Notice from Worksafe NZ?
/ YES NO
If YES, please attach details
Have you ever been prosecuted under the Health and Safety in Employment Act?
/ YES NO
If YES, please attach details
Do you keep a register of Personal Protection Clothing and Equipment issued to staff?
/ YES NO

Has your Health and Safety Management System been externally audited within the last 12 months?

/ YES NO
If YES, please attach details
Please provide the names and contact details of two recent clients who can verify your safety standards and on site performance.
Name & Company / Tel No. and/or email address
PART B
Quality Management
1.Does your company maintain an ISO 9000 certified Quality Management System? Or equivalent Quality Assurance Programme / YES NO
2. Does your company have a Quality Assurance Policy and / or Manual / YES NO
If your answer to Question 1 or 2 above is YES - please attach a copy of your current certification / Policy then move onto Section C.
If your Company does not have a formal Quality Management System, continue onto Q3.
3. Do you have employees responsible for ensuring your work activities comply with Siconferguson requirements?
And are their authorities and responsibilities defined and documented? / YES NO
YES NO
4. Do you have procedures for:
Purchasing materials
Inspecting and testing materials for specification compliance
Compliance with manufacturers recommendations for storage and handling
Provision of MSDS and safety information / YES NO
YES NO
YES NO
YES NO
5. Are procedures for corrective and preventative action documented?
Including recording, investigating and improvement measures / YES NO
6. Is there a documented process to review your quality performance? / YES NO
Please attach any information you have to support your answers above
PART C
Environmental Management
1. Does your company maintain an ISO 14001 certified Environmental Management System? / YES NO
2. Is your organisation certified to any other Environmental Management System e.g. Enviromark? / YES NO
If YES to either of the above, please attach a copy of your certificate and proceed to Section D
If you answered NO, please continue with the rest of this section
3. Does your company have a documented Environmental Management System or plan(s)? / YES NO
4. Has your company identified and assessed the significant environmental aspects of its activities and their associated risks and impacts on the environment? / YES NO
5. Does your company have a specific policy or action plan relating to:
Waste (e.g. recycling and reduction measures)
Transportation (e.g. fuel conservation and maintenance schedules)
Environmental improvement initiatives (e.g. Carbon footprint) / YES NO
YES NO
YES NO
6. Do you have employees responsible for ensuring your work activities comply with environmental requirements? Including compliance with the Resource Management Act, Regional / Local Council Plans, Permits and Consents. / YES NO
7. Do you have a process for training and informing your staff on relevant environmental issues? / YES NO
8. Within the last 3 years has your company
Had any infringement, abatement or enforcement notices served on it by an environmental authority?
Been prosecuted for non-compliance with the Resource Management Act, a resource consent or permit?
IfYES to either of the above please provide details on a separate sheet / YES NO
YES NO
PART D
Organisation Declaration(PLEASE READ FIRST)
1 / The information recorded in, or attached to this questionnaire is a true and accurate record of my/our organisations Safety, Environmental and Quality management records and documentation
2 / I/We agree to advise Sicon Ltd of any significant change in circumstances that might impact the Safety, Environmental and Qualityperformance declared in this questionnaire, attachments or answers
3 / I/We will provide site specific plans, including safety and environmental hazards, control methods, and hazardous substance registers prior to any work being commenced on any contract, which we may be contracted by Sicon Ltd
4 / I/we agree to complete a Sicon Ltdsub-contractor agreement where this is required for any contract
5 / I/we agree that if asked for, now or at any time in the future, we will provide or allow inspection and audit by a Sicon Ltd Safety Person, of our Safety, Environmental and Qualityprocesses, documentation or records we have confirmed in this questionnaire or that are covered by any certification declared.
6 / By signing below you agree that:
You have reviewed the expectations in the sub-contractor handbook
You have had any questions answered to your satisfaction: safety, quality, environmental etc
Signed

Position Date

Note to Sub-Contractors:

The completion of this document cannot assume that you will be placed on our approved contractor’s pre qualification list. The documents you supply will help us evaluate whether you meet our criteria. It is a guide for us to ensure that you are meeting your obligations under the Health and Safety in Employment Act.

Sicon Ltd- OFFICE USE ONLY
Date Sent / Date Returned
Management to complete this section
Qualifications satisfactory / YESNO
References satisfactory / YESNO
Evidence of Health and Safety Practices are satisfactory / YESNO
Evidence of Quality Practices are satisfactory / YESNO
Evidence of Environmental Practices are satisfactory / YESNO
Evidence of appropriate insurance satisfactory / YESNO
Further clarification required / YESNO
Clarification letter sent to Sub-Contractor / Yes / No / Date:
Management acceptance Date
Risk Manager
Sub-Contractor application approved / Yes / No / Date
a)Confirmation letter sent to Sub-Contractor
b)Sub-Contractor details entered onto sub-contractor module(Suppliers) / Date:

Printed: 17 November 2018Page 1 of 5