Modello Per Form

/ FORM
SPECIFIC QUESTIONNAIRE FOR
HEALTH, SAFETY AND ENVIRONMENT / Doc. n. FORM-COR-PRO-009-E
Rev. 01 / Data 27/02/15
Pag. 1 di 3
Ref. Doc. STD-COR-PRO-001

Specific Questionnaire For Health, Safety And Environment

With reference to the qualification process of your Company, please provide the following documentation for the HSE evaluation.

Item / Question / Att.: “See Note 1” / Reply
01 / LEADERSHIP & COMMITMENT
Does your Company have a dedicated HSE program of cultural change?
If YES, please provide details.
If NOT, please explain how does your Company promote a positive culture towards HSE matters? / O
02 / POLICY & OBJECTIVES
a / Does your Company have HSE Policies? (e.g. Health & Safety Policy, Environment Policy, Smoking Policy, Alcohol and Drug Policy, others).
If YES, please provide attachment. / Y
b / Does your Company have any strategic HSE objectives? If YES, please provide last year examples. / Y
03 / ORGANIZATION AND HSE RESPONSIBILITIES
Please provide the Organization Chart of your Company and explain how is your organization structured to manage HSE effectively (both at Company level and at project level). / Y
04 / COMPETENCE ASSURANCE & HSE TRAINING
a / How does your Company ensure and measure competency of its personnel? Please provide details. / O
b / Please provide a copy of your Company annual HSE training plan, showing subjects and intended participants. / Y
05 / DOCUMENT SYSTEM
a / Please provide a copy of your HSE Manual. / Y
b / Please provide a table of content of your Company Document System, highlighting HSE relevant procedures. / Y
06 / RISK ASSESSMENT
a / How do you assess Health & Safety risks related to your activity? Please provide a copy / an example of your Company / Project Health & Safety risk assessment, including measures in place to minimize risks. / Y
b / How do you assess Environmental Aspects and Impacts related to your activity? Please provide a copy / an example of your Company / Project Environment risk assessment, including measures in place to minimize risks. / Y
07 / HSE PERFORMANCE MONITORING
a / Please fill in the table chart with your safety statistical data of the last 5 years, according to definitions provided in the note (“See Note 2”). / O / Last 5 Years / Total
Worked
man-hours / Fatality / LTIFR / TRIFR / SR / Near Miss
b / In case of Fatality or severe Accidents occurred in the last 5 years, please provide your accident investigation report and explain preventive and corrective actions implemented. / Y
(if any)
c / In case of any Environmental Accident occurred in the last 5 years, please provide your accident investigation report and explain preventive and corrective actions implemented. / Y
(if any)
08 / OHSAS 18001 and ISO 14001 certificate
Does your Company have valid OHSAS 18001 and ISO 14001 certificates?
If YES, please provide a copy of the certificates. / Y

Notes for compilation

1)Column Att.: Y means YES, Attachment REQUIRED – O means Attachment OPTIONAL

2)Definitions related to question 7a:

Fatality: Termthat defines a death resulting from a work related injury, regardless of the time intervening between the injury and the death. Fatalities are included when calculating the number of Lost Time Injuries and LTI Frequency Rate.

Lost Time Injury (LTI):A LTI is any work-related injury which renders the injured person temporarily unable to perform any regular Job or Restricted Work on any day/shift after the day on which the injury occurred (in this case “any day” includes rest day, weekend day, and holiday). The day of the Accident is not counted when calculating Lost Workdays. Lost Time Injuries includes: Fatalities, Permanent Total Disabilities, Permanent partial disabilities and Temporary Permanent Disabilities.

Lost Time Injury Frequency Rate (LTIFR):N. LTI x 1,000,000 / Total Worked Man-hours.

Lost Work Days(LWD):The total number of calendar days in which the injured person was unable to work as a result of a Lost Time Injury. The calculation of lost workdays starts from the second day when the accident occurred and includes the number of calendar days counted until the injured person is fit for work. In the case of a Fatality or Permanent Total Disability no Lost Workdays are recorded.

Medical Treatment Cases (MTC): Term to define any work-related injury (infected wounds, application of stitches, embedded foreign bodies in the eyes, etc.) that involves neither Lost Workdays nor Restricted Workdays but which requires repeated treatment by, or under the specific order of a physician, or could be considered as being in the province of a physician. Medical Treatment does not include First Aid even if this is provided by a physician or registered professional personnel.

Near Miss:It is an hazardous Event which, under slightly different circumstances, could have caused an Accident affecting even people, environment or assets.

Severity Rate (SR): N. LWD x 1,000 / Total Worked Man-hours.

Total Recordable Incident (TRI):Term to define the sum of Lost Time Injuries, Work Restricted Cases and Medical Treatment Cases.

Total Recordable Incident Frequency Rate (TRIFR):N. TRI x 1,000,000 / Total Worked Man-hours.

Work Restricted Cases (WRC): Any work-related injury other than a fatality or lost work day case which results in a person being unfit for full performance of the regular job on any day after the occupational injury.

Work performed might be:

• an assignment to a temporary job

• part-time work at the regular job

• working full-time in the regular job but not performing all the usual duties of the job.

An injury can be classified as WRC only upon written non objection statement of the injured person.

Where no meaningful restricted work is being performed, the incident should be recorded as a lost time injury (LTI).