JO – CHESM Qualification Questionnaire Core Questions
Joint Operations (JO) – CHESM Qualification Questionnaire Core Questions
1. General /Contractor Company Name
Service Provided
JO Department Sponsor
JO Contract Owner
Number of Employees Supporting JO Operations
Contractor Representatives / Company Director/Manager:
Phone: Fax: email:
Site Supervisor:
Phone: Fax: email:
HES Representative:
Phone: Fax: email:
Contractor Management Representative:
Phone: Fax: email:
Date of last inspection/audit by a JO representative? / Click here to enter a date.
Contract Company was founded (Date)? / Click here to enter a date.
Years worked in JO
Completed By
(JO Assessor) / Name:
Position:
Phone:
Fax:
Email:
Date Submitted: Click here to enter a date.
Note: Please provide resume or work experience (curriculum vitae) for key leadership positions to include site supervisor, project manager, HES representative, and contactor management representative.
2. Health, Environmental and Safety Performance /
Are key element records listed in 2.1 – 2.10 available for the last three years?
Yes No / Comments:
Provide companywide information (previous three years of data) / 2010 / 2009 / 2008
2.1 / Total number of employee hours worked.
Specify the basis for exposure or employee hours: / 8 Hr. Shifts
12 Hr. Shifts
Other
2.1.2 / Total Kilometer driven
Use 200,000 man-hour & 1,000,000 Km driven based to calculate rates
2.2 / Number of Work-related fatalities
2.3 / Number of injuries resulting in days away from work (DAFW)
2.4 / Number of recordable injuries (TRI)
2.5 / Number of Motor Vehicle Crash (MVC)
Provide information for work performed within JO facilities or JO geographical region (previous three years of data) / 2010 / 2009 / 2008
2.6.1 / Total number of employee hours worked within JO facilities or JO geographical region
2.6.2 / Total Kilometer driven within JO facilities
2.7 / Work-related fatalities within JO facilities or JO geographical region
2.8 / Rate of injuries resulting in days away from work within JO facilities or JO geographical region
2.9 / Rate of recordable injuries within JO facilities or JO geographical region
2.10 / Rate of motor vehicle accidents within JO facilities or JO geographical region
2.11 / Have you received any regulatory citations or been involved in any court litigation related to HES incidents or noncompliance in the last three years? / Never: White colour flag
Once: Blue colour flag
Twice: Yellow colour flag
More than twice: Red colour flag
3. Health, Environmental and Safety Management /
3.1 HES Organization: Does your organization have the following:
a) A director or senior manager responsible for HES? / Yes / No
b) Does your organization have a part/full-time position assigned HES responsibilities? (Please describe.) / Yes / No
3.2 HES Benefits: Do you have or provide for your employees:
a) Medical insurance? / Yes / No
b) HES training? / Yes / No
3.3 HES Targets: What are your company’s annual HES targets in:
a) Safety: Determined or Not Determined / Yes / No
b) Health: Determined or Not Determined / Yes / No
c) Environmental: Determined or Not Determined / Yes / No
3.4 HES Written Plan: Does your written HES Plan include:
a) HES policy and management commitment and expectations? / Yes / No
b) Clearly defined HES responsibilities and accountabilities for managers, supervisors, and employees? / Yes / No
c) Resources for meeting HES requirements? / Yes / No
d) Periodic management system review of key processes, procedures, and standards to ensure compliance and performance improvement? / Yes / No
e) Document control and record retention process? / Yes / No
f) Written safe work procedures specific for your work? / Yes / No
g) Documented employee fitness for duty (skills, knowledge and physical/medical suitability for job) process? / Yes / No / N/A
h) Inspection/Audit program? / Yes / No
i) Hazard identification and risk control? / Yes / No
3.5 Employee Engagement:
a) Periodic HES performance appraisals for all employees? / Yes / No
b) Do your employees participate in team activities to improve HES performance? / Yes / No
c) Do your employees have the authority to stop work for safety reasons? / Yes / No
d) Are HES issues, inspection results, investigation results and learnings communicated to employees? / Yes / No
3.6 HES Meetings: Do you hold periodic HES Meetings that include:
Field Supervisors? / Yes / No
Employees? / Yes / No
Sub-contractors? / Yes / No
a) Do you hold daily toolbox safety meetings? / Yes / No
b) Are the HES meetings documented with minutes and attendees list? / Yes / No
c) Do Managers participate in safety meetings? (Job titles?) / Yes / No
3.7 Sub-Contractors:
a) Does your company use sub-contractors?
If Yes, provide current list of sub-contractor companies. If No, select “N/A” for remaining questions of this section. / Yes / No
b) Is there a written contractor safety management process? (1. Pre qualification and/or selection; 2. Pre job activities and work in progress; 3. Final evaluation.) / Yes / No / N/A
c) Is there a written contractor safety management process? / Yes / No / N/A
d) Do you evaluate the ability of sub-contractors to comply with applicable HES requirements as part of your selection process?
Provide example or criteria. (1. Expertise HES dedicated personnel) only; 2. Materials/equipments; 3. Other HES programs like training / Yes / No / N/A
3.8 Inspections and Audits:
a) Do you have a written inspection/audit procedure? / Yes / No
b) Do you conduct self-inspections and audits and document them? / Yes / No
c) Do you track/measure corrective actions to verify completion within assigned time? Describe verification process. / Yes / No
3.9 Hazard Identification and Control:
a) Do you have a documented process to identify work-related hazards including task, work location, natural conditions, and materials?
For 3.9.a. (1. Procedure/written process in place, 2. Include title of task and work location, 3. Include also natural conditions and materials) / Yes / No
b) Are practices and procedures developed based on the hazards identified to mitigate the risk to employees? / Yes / No
3.10 Incident Reporting, Investigation and Statistical Data:
a) Do you have a written process to report, investigate, and record incidents?
For 3.10.a. (1. Procedure/written process in place, 2. Inconsistent implementation, 3. Consistent implementation) / Yes / No
b) Does your process provide a technique for root cause analysis? / Yes / No
c) Do you have a process in place to track recommendations and corrective actions to completion within the assigned time?
For 3.10.c. (1. Procedure/process in place, 2. Inconsistent implementation, 3. Consistent implementation) / Yes / No
d) Does your company have a process to share lessons learned on incidents and near misses?
For 3.10.d. (1. HES Meeting, 2. Bulletin Board, 3. Town hall Meeting after accident or other communication media) / Yes / No
3.11 Behavior-Based Safety:
a) Do you have a behavior-based safety (BBS) process in place? / Yes / No
3.12 Personal Protective Equipment (PPE):
a) Do you have a written PPE program that includes? / Yes / No
b) Is the program communicated to all employees? / Yes / No
c) Do you provide the required PPE for the jobs that you perform? / Yes / No
3.13 Regulatory Compliance:
a) Do you know the HES-related government and local regulations pertaining to your work? If you do, please list titles of the regulations. / Yes / No
3.14 Pollution Prevention:
a) Does your company have waste management plans? / Yes / No / N/A
b) Have all your waste streams been identified? / Yes / No / N/A
c) Do you have a site-specific spill prevention program? / Yes / No / N/A
3.15 Emergency Preparedness and Response:
a) Do you have written site-specific emergency response plans?
Note: Small companies may not have their own plan but still need to have site-specific emergency response plans. / Yes / No
b) Do you document emergency response training and drills?
Note: Small companies still need to document participation in site emergency drill at owner’s facility. / Yes / No
4. Fitness For Duty: Skills, Knowledge, and Training /
4.1 Short-Service Employee (SSE): employees new to your company or new in their work assignment
a) Do you have a documented SSE program? / Yes / No
4.2 Craft Training:
a) Have employees been trained in appropriate job skills? / Yes / No
b) Are employees’ job skills certified where required by regulatory or industry standards? / Yes / No
4.3 Health, Environmental and Safety Orientation:
a) Do you have a HES orientation program for newly hired employees? / Yes / No
b) Does your orientation program include the requirements as agreed in the contract HES exhibit? / Yes / No
4.4 Health, Environmental and Safety Training Content:
a) Do you know the local regulatory and JO HES training requirements for your employees? / Yes / No
b) Have your employees received the required HES training and retraining? / Yes / No
c) Do you provide specific supervisory HES training for new supervisors and refresher training for existing supervisors? / Yes / No
d) Does the training program include work practices and procedures such as:
· General safe work practices? / Yes / No
· Equipment lock-out and tag-out (LOTO)? / Yes / No / N/A
· Permit-to-work procedures? / Yes / No / N/A
· Fall protection? / Yes / No / N/A
· Personal protective equipment? / Yes / No
· Vehicle/Driving safety? / Yes / No / N/A
· Electrical equipment grounding? / Yes / No / N/A
· Incident reporting and investigation? / Yes / No
· Emergency preparedness and response? / Yes / No
· Environmental protection? / Yes / No / N/A
· Hazard identification and control? / Yes / No
4.5 Training Records:
a) Do you have HES and crafts training records for each individual employee that include employee identification, date of training, and name of trainer? / Yes / No
5. Fitness For Duty: Medical Suitability and Industrial Monitoring /
5.1 Medical Services:
a) Do you have a process to provide medical treatment for your employees? / Yes / No
5.2 Medical Examination:
a) Do you conduct medical exams for employees for pre-placement job capability? (1. General checkup, 2. Work specific checkup): “0” for No; “0.5” for conducting 1 for field work; “1.0” for office work and conducting 1 and 2 for field work. / Yes / No / N/A
5.3 Substance Abuse:
a) Do you have a substance abuse monitoring program? / Yes / No / N/A
5.4 Industrial Hygiene (IH):
a) Do you perform IH monitoring on your employees?
If you do, please indicate for what substances (e.g., asbestos, benzene, lead, radiation, total hydrocarbons and welding fumes). / Yes / No / N/A
b) Do you have a hearing conservation program with annual testing? / Yes / No / N/A
6. Equipment and Materials /
6.1 General:
a) Do you maintain updated and accessible MSDS for paints and chemical? / Yes / No / N/A
b) Does your company have a motor vehicle safety policy and process? / Yes / No
6.2 Equipment:
a) Do you conduct, document and follow up inspections on operating equipment (e.g., cranes, forklifts)? / Yes / No / N/A
b) Do you maintain operating equipment in compliance with regulatory requirements including certification, calibration, maintenance system, etc.? / Yes / No / N/A
Version 3.1. Revised 20 Feb. 2011. 15
JO Qualification Questionnaire Core Questions2011-V. 3.1.docx