Please complete this questionnaire and return it to Manor Group Investment Trust.

1. Scope

This assessment is used by Manor Group to assess the extent to which its Contractors are committed to Health and Safety. The assessment considers a wide range of issues relevant to Health and Safety. Based on the assessment response, Manor Group will determine if the Contractor qualifies as an “Approved Contractor”.

2. Contractor Details

Name of Company

Postal Address

Street Address

Principle Contact/Title

Phone

Mobile

Project or Type of Service to be Provided

Site Location for Project

Please attach a signed and dated copy of your Organisation Structure

3. Questions to be Answered by Contractor

3.1 Policies

Give Yes or No

1.     Does your organisation have a written Health and Safety Policy?

YesNo

2.     Does your organisation have a written Drug and Alcohol Policy?

YesNo

3.     Does your organisation have any other Written Policies?

YesNo

Attach copies of policies you have answered yes to above.

3.2  Health Monitoring

Give Yes or No

4.     Does your organisation have a system in place to monitor the health of employees

YesNo

If yes, what is the frequency of the health checks (please select)    

Provide evidence of your health monitoring reports to this document

3.3 Insurance

Give Yes or No

5.     Do you have Public Liability Insurance?

YesNo

6.     Do you have Motor Vehicle Insurance?

YesNo

7.     Sole Trader – Do you have personal injury insurance?

YesNo

8.     Do you have ACC Cover?

YesNo

Attach copies of Insurance policies to this document

3.4 Occupational Health and Safety Systems

Give Yes or No

9.  Is your organisation a member of the an ACC Workplace Discount Program

YesNo

10.  What is your current level of Accreditation? (please circle) Primary Secondary Tertiary

YesNo

11.  Do you conduct internal/external audits?

YesNo

 

3.5 Training and Competencies

Give Yes or No

12.  Do all your employees and sub-contractors hold Current qualification/licences and permits to conduct their work?

YesNo

13.  Do you have a documented list of the skills and training your employees require?

YesNo

14.  A system for testing the competency of your employees for on the job training?

YesNo

15.  An employee induction programme that includes Health and Safety Training?

YesNo

16.  Have all your employees been trained on how to identify hazards in the workplace?

YesNo

Provide evidence of your training register.

Please explain how you test and document the competency of your employees:

3.5 Incident Management Reporting

Give Yes or No

17.  Does your organisation have processes and procedures for reporting incident and accidents

YesNo

18.  Are all incidents and accidents investigated?

YesNo

19.  Have all your employees been trained in incident reporting?

YesNo

20.  Has your organisation had Fatalities, Serious Harm Injuries, Lost Time Injuries and incidents causing property damage during a contract in the last year? (If so how many)

YesNo

21.  Has your organisation been prosecuted for a Health and Safety or Environmental Breach?

YesNo

If so please explain and provide a copy of your incident report. Please indicate how you have taken steps to prevent a reoccurrence of this:

3.6 Plant and Equipment

Give Yes or No

22.  Does your organisation have a documented system for maintenance of all plant and equipment?

YesNo

23.  Do you ensure your employees receive adequate training and have the correct licences or certificates to operate the plant and equipment they use?

YesNo

24.  Do you ensure that all plant and equipment is fitted with the correct and legal safety provisions (eg seat belts, roll over protection)?

YesNo

25.  Is appropriate PPE issued to your employees to carry out work and are the staff trained in the correct use, maintenance and storage of their PPE?

YesNo

Attach evidence of relevant training records to this document and maintenance records

 

3.7 Emergency Procedures

Give Yes or No

26.  Does your organisation have emergency response procedure to deal with work-site emergencies?

YesNo

27.  Have your employees been trained and understand on what to do in an emergency situation?

YesNo

28.  Have your employees been trained in First Aid?

YesNo

29.  Do you have an emergency controller and area wardens who will lead an emergency response?

YesNo

30.  Will you be conducted high risk activities eg work at heights, in confined space? Do you have a rescue plan in place and staff trained to carry out rescues in these particular situations?

YesNo

Attach evidence of your Emergency Rescue plans.

3.8 Hazard Management  

Give Yes or No

31.  Does your organisation have a process to identify, report and control hazards in the workplace?

YesNo

32.  Does your organisation have Task Analysis Work Sheet (TAWS), Job Safety Analysis System (JSA)

YesNo

33.  Do you regular update and review your hazard register?

YesNo

Attach an example of TWS/ JSA and a copy of your hazard register identifying the hazards you will be bringing onto site.

 

3.9 Operating Procedures - Do you have Work Safe Instructions/Procedures for:

Give Yes,No or N/A

34.  Work at Heights?

YesNoN/A

35.  Working on Roofs?

YesNoN/A

36.  Isolation of Energy Sources for Plant and Equipment?

YesNoN/A

37.  Chemical Management (hazardous materials)?

YesNoN/A

38.  Working on electrical Services?

YesNoN/A

39.  Working on Water Services?

YesNoN/A

40.  Lifting and Loading – Crane Operations?

YesNoN/A

41.  Working on Gas services?

YesNoN/A

42.  Demolition Operations?

YesNoN/A

43.  Hot Work (welding, gas cutting)?

YesNoN/A

44.  Forklift/Loader Operations?

YesNoN/A

Provide evidence by attaching copies of your procedures.

 

3.10 Selection of Sub-Contractors  

Give Yes or No

45.  Does your organisation have a process to assess the health and safety and training capacity of sub-contractors?

YesNo

46.  Is the performance of sub-contractors monitored as work is undertaken?

YesNo

Provide evidence by attaching copies of your process that you use to select and monitor sub-contractors.

 

4. Other relevant information

If there is any other information you wish to provide please include it here:

 

5. Conditions

It is an expectation that all contractors, sub-contractors and their employees will comply with the relevant Health and Safety statutory requirements and comply with the terms and conditions in the Manor Group Investment Trust Company Induction Commitment and Expectation Booklet while conducting work on any of our sites.

 

(Please draw your signature with your mouse, your finger, tablet or smartphone)

Signed for and on behalf of the contractor by:

Full Name of Contractor Representative:

(Please draw your signature with your mouse, your finger, tablet or smartphone)

Signature:

Date:

 

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