Provide Examples of Work Carried out Previously, Which Is Comparable in Size and Nature

Story Homes / SHE Form /
Safety, Health & Environmental System / Page | 1
Assessment for Consultants and Contractors / Issue date: October 2013
Project: / Issued by: / Date:
Address: / Telephone:
Fax:
Contractor’s Name:
Address: / Telephone:
Fax:
E-mail:
Completed By:
Signature: / Position: / Date:
Status: / Subcontractor / Supplier / Labour-only / Consultant / Delete those that do not apply
Services Offered: / Provide a brief description
Territory Covered:
(Please tick all that apply) / National / North West / Scottish Borders
Cumbria / North East / Central Scotland
Company Registration Number
VAT Registration Number
Unique Tax Reference (UTR) Number
National Insurance Number (sole trader/partnership)
Bank:
Account Name:
Address: / Account Number / Sort Code
Financial Standing: / Turnover / Profit after tax
2010 – 11
2011 – 12
2012 – 13
Please answer the following questions and supply the relevant information as requested providing supporting details and documentation separately.

1. Provide examples of work carried out previously, which is comparable in size and nature to this project

Examples enclosed: Yes / No

1. If more than five people are employed, provide a copy of your organisation safety policy as requested by S.2(3) of the Health and Safety at Work Act 1974.

Copy policy supplied: Yes / No

1. Who in the organisation has day to day responsibility for health and safety matters?

Name: Position:
Address:
Telephone: Fax:

1. Provide details of the experience and qualification(s) of the person named in 3 above.

Curriculum Vitae enclosed: Yes / No

1. Who will be providing advice on health and safety issues on this project/generally?

Name: Position:
Address:
Telephone: Fax:

1. Provide summary of the arrangements in place to discharge the duties within CDM.

Summary enclosed: Yes / No

1. Provide matrix of the health and safety training provided to individuals within your organisation, including minimum levels to be achieved.

Matrix enclosed: Yes / No

1. Provide details of your compliance to the industry initiative of a fully qualified workforce, e.g. CSCS.

Details enclosed: Yes / No

1. Please indicate the number of employees & subcontractors and the %age of operatives which carry CSCS cards

Directly employed: ______Total of which ______% carry CSCS cards.
Subcontract: ______Total of which ______% carry CSCS cards.

1. Provide details of your systems for monitoring safety, health and environmental standards on site. Include copies of KPI’s where possible.

Details enclosed: Yes / No

1. Include information on how you consult with your workforce on health and safety matters.

Information enclosed: Yes / No

1. Include details of reportable events that have occurred in the last three years, including Subcontract and direct employees.

Details enclosed: Yes / No

1. For reportable events identified above, provide details on the remedial action taken.

Details enclosed: Yes / No

1. Have any formal notices or legal proceedings been taken against the company by the enforcing authorities in the last three years.

Details enclosed: Yes / No

1. Provide details of any accidents/incidents reported by, or on behalf of, your organisation to the Health & Safety Executive during the last three years (as required by the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (SI 1995/3163).

Details enclosed: Yes / No

1. Provide details on your arrangements for assessing the competency of any Subcontractors you will employ.

Details enclosed: Yes / No / Not applicable

1. Detail your procedures for evaluating and controlling risk in particular review of significant health and safety issues via risk assessment/method statement and detail how these procedures are monitored.

Details enclosed: Yes / No

1. How will you ensure cooperation and coordination with the design team and the collation of information for the health and safety file.

Details enclosed: Yes / No

1. Provide details to evidence that your Company holds a valid form of SSIP (Safety Schemes in Procurement) Accreditation, such as CHAS or SAFEcontractor.

Details enclosed: Yes / No

1. Do you operate a call out service; if yes:

1. Is it a 24-hour service? Yes / No

1. What geographical area do you cover?

1. What is your typical response time?

1. Please list contact names and numbers for your call-out service

1. General

1. 24-hour

Certification to ISO Standards
Not mandatory but provides assurance that your Management Systems are independently certified / Yes / No
ISO 9001 Certification
ISO 14001 Certification
OHAS 18001 Certification
Trade Association Details: e.g. Gas Safe, NICEIC, NFDC etc. Attach a copy of any certificates, if available
Trade Organisation: / Registration Number / Expiry Date
Insurances: / Provider / Policy Number / Expiry Date / Cover (£M)
Employers Liability
Public & Products Liability
Professional Indemnity

CHECKLIST OF INFORMATION REQUIRED

Certificate of Incorporation (If Limited Coy.) / Question 12 – Reportable events
Certificate of VAT Registration / Question 13 – Remedial action taken
Copy of UTR Number / Question 14 – Formal notices/legal action
Copy/copies of NINO cards / Question 15 – RIDDOR
Question 1 – Examples of recent work / Question 16 – Assessing subcontractors
Question 2 – Health & Safety Policy / Question 17 – Evaluate & Control risk
Question 4 – CV of Responsible Person / Question 18 – Information for H&S file
Question 6 – CDM / Question 19 – SSIP
Question 7 – Health & Safety Training Matrix / Copies of ISO Certification
Question 8 – CSCS / Copies of current trade memberships
Question 10 – SHE monitoring systems / Copies of current insurance policies
Question 11 – Details of consultations

Data Protection

All information provided will be treated in the strictest confidence. In the event of any individual or business requesting access to this information (data) under the Data Protection Act (1998), Story Homes Limited will contact you first to request permission to reveal the said information.