Contractor Safety, Health and Environmental Management System

(CSMS) Guidelines

Pre-Qualification Forms

Pre-Qualification
New Contracts
Qualification Phase: Select A Qualified Contractor

Risk Assessment
Pre-Qualification
Selection CSMS

Contract Award
Data Bank
Contract Implementation Phase: Ensure Field Safe Work

Pre-Job Activity Work In Progress Final Evaluation

 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Form CSMS/PQ/01

PRE-QUALIFICATION

Date :

Project Period : ------

Job Title : INTEGRITY MANAGEMENT & CORROSION SERVICES

Contract No : ------

Work Location : Company & Contractor Jakarta Office and Company

Offshore

Contractor Name :

Address :

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Form CSMS/PQ/02: Contractor HSE MS Questionnaires

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Company Name:

Work Subject:

SECTIO N 1 – LEADERSHIP AND TO P MANAGEMENT CO MMITMENT

1. Commitment to HSE through leadership
a) How are senior managers is top management personally involved in HSE management?

b) Provide evidence of commitment at all levels of the organization by:·

(i) Stating this year's company targets for HSE performance·

(ii) Describing how you ensure that your organization understands and is committed
to deliver your company HSE targets

c) How do you promote a positive culture towards HSE matters?

d) Provide your current O rganization chart

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTION 2 – POLICY AND STRATEGIC OBJECTIVES

2.1. HSE Policy & Documents

a) Does your company have an HSE policy document that is applied?

(Yes/ No) If yes, please attach.

b) Who has overall and final responsibility for HSE in your organization?

c) How do you ensure HSE Policy compliance and communication at site?

2.2. Availability of Policy Statements to Employees

How do you communicate your company's policy to your employees including any changes?

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTIO N 3: O RGANIZATIO N, RESPO NSIBILITY, RESO URCES, STANDARDS AND

DO CUMENTATION
3.1. O rganizations - Commitment and Communication

a) How is management involved in HSE activities, objective setting and monitoring?

b) What provision does your company make for HSE communication and meetings?

3.2. Competence and Training of Manager/ Supervisors/ Senior Site Staff/ HSE Advisor

Have the managers and supervisors at all levels that will plan, monitor, oversee and carry out the
work received formal HSE training in their responsibilities with respect to conducting work to HSE
requirements? (Yes/ No)

If yes, please attach the training matrix.

3.3. Competence and General HSE Training

a) What arrangements does your company have to ensure employees have knowledge of basic
industrial HSE, and to keep this knowledge up to date?

b) What arrangements does your company have to ensure ALL employees, including sub
contractors, also have knowledge of your HSE policies and practices?

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTIO N 3: O RGANIZATIO N, RESPO NSIBILITY, RESO URCES,

STANDARDS AND DO CUMENTATIO N
3.4. Specialized Training
Have you identified areas of your company's operations where specialized training is required to
deal with potential hazards? (Yes/ No)

If Yes, please provide the list (e.g. radioactive, asbestos, explosive, diving, etc).

3.5. HSE Q ualified Staff - Additional Training

Does your company have HSE specialist (related to your company's services) who can provide
training for other employees? (Yes/ No)

If Yes, please attach the curriculum vitae

3.6. Assessment of Suitability of Subcontractors

a) Do you employ sub-contractor(s) for the intended service? (Yes/ No)

If No, please go to the question 3.7.

Do you have sub-contractor(s) selection procedure in term of HSE?

b) How do you assess your sub-contractor(s) to ensure they comply with your company's HSE
policy and standards?

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTIO N 3: O RGANIZATIO N, RESPO NSIBILITY, RESO URCES,

STANDARDS AND DO CUMENTATIO N
3.7. Standards

a) What kind of HSE regulatory or industrial standards that your company refer to for the
intended service?

b) How do you ensure these are met and verified?

SECTIO N 4: HAZARDS AND EFFECT MANAGEMENT

4.1. Hazards and Effect Management
Does your company have procedure for the identification, assessment, control and mitigation of
hazards and effects? (Yes/ No)

If Yes, please attach the index/ table of content including the sub-index.

4.2. Exposures of the Workforce

What systems are in place to monitor the hazard's exposure of your workforce e.g. chemical or
physical agents?

4.3. Handling of Potential Hazards

How is your workforce advised on potential hazards, e.g. chemicals, noise, radiation, etc.,
encountered in the course of their work?

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTION 4 : HAZARDS AND EFFECT MANAGEMENT

4.4. Personnel Protective Equipment
a) What arrangements does your company have for provision and unkeep of protective
equipment and clothing, both standards issue, and that required for specialized activities?

b) Do you provide appropriate personal protective equipment (PPE) for your employees?
(Yes/ No)

Please provide a listing of the PPE for the scope of this work.

c) Do you provide training on how to use PPE? (Yes/ No)

Explain the content of the training and any follow-up

d) Do you have a program to ensure that PPE is impacted and maintained?

4.5. Waste Management

a) What systems are place for identification, classification, minimization and management of
waste?

b) Please provide the number of accidents resulting in environmental damage in the amount
greater than $50,000 for the last 24 months. Attach copies of any governmental reports
submitted.

c) Do you have procedures for waste disposal? (Yes/ No)

d) Do you have procedures for spill reporting? (Yes/ No)

e) Do you have procedures for spill clean up?(Yes/ No)

f) Please provide details at any of your equipment related to environmental matters.

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTION 4 : HAZARDS AND EFFECT MANAGEMENT

4.6. Industrial Hygiene
Do you have an industrial hygiene program? (Yes/ No)

Please describe this process. If Yes, please provide the list.

4.7. Drugs and Alcohol

Do you have a drugs and alcohol policy in your organization? (Yes/ No) If yes, please attach

SECTION 5: PLANNING AND PROCEDURES

5.1. HSE or Operations Manuals
a) Do you have HSE procedures? (Yes/ No) If Yes, please attach the list of content

b) How do you ensure that the working practices and procedures used by your employees on-site
are consistently in accordance with your HSE policy objectives and arrangements?

5.2. Equipment Control and Maintenance

How do you ensure that plant and equipment used within your work environment, on-site, or at
other locations by your employees are correctly registered, certified with regulatory requirement,
inspected, controlled and maintained in a safe working condition?

5.3. Transport Safety Management and Maintenance

What arrangement does your company have for vehicle incidents prevention?

5.4. Lifting Operation Procedure (if applicable)

Do you have any procedures to control the work involved in lifting operation?

5.5. Maintenance Schedule of Lifting Operation Equipments (if applicable)

Do you have any inspection, testing, maintenance and certification programs and schedule for
lifting equipments e.g. crane, forklift and rigging equipment?

5.6. Competency of Lifting Operation Personnel (if applicable)

Do you have any system to ensure that the lifting teams e.g. lifting equipment operators,
signalmen and rigging personnel are competent?

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTIO N 6: IMPLEMENTATION AND PERFORMANCE MONITO RING

6.1. HSE Management and Performance Monitoring of Work Activities
a) What arrangement(s) does your company have for supervision and monitoring of HSE
performance?

b) What arrangements does your company have for passing on any results and findings of this
supervision and monitoring to your:

(i) Top/ Base management

(ii) Site employees

c) Has your company received any award for HSE performance achievement? (Yes/ No)

6.2. Statutory Notifiable Incidents/ Dangerous O ccurrences, Improvement Requirement and Prohibition
Notices
Has your company suffered any improvement requirement or prohibition notices on statutory
notifiable incidents/ dangerous occurrences by the relevant national body, regulatory body for
HSE or other enforcing authority or been prosecuted under any HSE legislation in the last five
years? (Yes/ No)

If yes, please give the number of occurrences and its short description.

6.3. HSE Performance Records

a) Please provide statistical details of your HSE performance over the past 3 years (if not
recorded/ applicable please mark N/ R or N/ A)
Total Number Frequency
(incl. All contract & sub contract personnel) (based on OSHA)

 Fatalities
 Loss Time Incidents (LTI)
 Total Recordable Cases (e.g. Medical Treatment, Restricted Work, Transfer to Another Job,
Unconsciousness)

b) How is health performance recorded?

c) How is environmental performance recorded?

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

SECTIO N 6: IMPLEMENTATION AND PERFORMANCE MONITO RING

6.4. Incident Investigation and Reporting
a) Do you have a procedure for the investigation, reporting and follow-up of accidents,
dangerous occurrences or occupational illnesses? (Yes/ No) If yes, please attach

b) How are the findings following an investigation, or a relevant incident occurring elsewhere,
communicated to your employees?

Please attach an example of investigation reports during the last 12 months.

SECTIO N 7: AUDIT AND REVIEW

a) Do you have a written procedure on HSE auditing? (Yes/ No)

b) How does this procedure specify the standards for auditing, including schedule, coverage and
the qualifications for auditors?

c) How is the effectiveness of audit verified and how does management report and follow up
audits?

SECTIO N 8: EMERGENCY RESPO NSE PRO CEDURE

Do you have an emergency response plan? (Yes/ No) If yes, please attach

SECTIO N 9: HSE MANAGEMENT - ADDITIO NAL FEATURES

Does your company hold association(s) membership? (Yes/ No)

If yes, please provide the list

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