Questionnaire Forms For Safety

XYZ HEALTH AND SAFETY QUESTIONNAIRE FOR TENDERERS
This questionnaire forms part of the tender process and is to be completed by tender’s and submitted with
their tender offer. Yes / No

1. Safety and Health Policy Yes No Mark
1.1 Is there a safety & health policy with clearly stated objectives? 􀀀 􀀀 (1)
1.2 Are the objectives communicated to & understood by employees? 􀀀 􀀀 (1)
1.3 Is the policy signed by the General Manager? 􀀀 􀀀 (2)
1.4 Is it displayed in all work areas? 􀀀 􀀀 (1)
Marks obtained out of 5

2. Responsibility/Accountability
2.1 Do duty statements exist and do they define safety & health responsibilities? 􀀀 􀀀 (2)
2.2 Are all employees fully conversant with their duty of care responsibilities? 􀀀 􀀀 (1)
2.3 Are employees regularly evaluated against their responsibilities? 􀀀 􀀀 (1)
2.4 Are safety and health issues taken into account when purchasing equipment? 􀀀 􀀀 (1)
2.5 Is there a flow chart to enable identification of individual responsibilities? 􀀀 􀀀 (1)
2.6 Is there a documented disciplinary procedure? 􀀀 􀀀 (1)
Marks obtained out of 7

3. Consultative Procedures
3.1 Are Safety and health representatives elected by the workforce? 􀀀 􀀀 (1)
3.2 Have they attended an accredited training program, of had any formal training? 􀀀 􀀀 (2)
3.3 Are the representatives members of the health & safety committee? 􀀀 􀀀 (1)
3.4 Is the committee chaired by senior management? 􀀀 􀀀 (2)
3.5 Are minutes kept and made available on request? 􀀀 􀀀 (1)
3.6 Does the committee develop action plans? 􀀀 􀀀 (1)
Marks obtained out of 8

4. Hazard/Risk Management
4.1 Is there a documented risk assessment/management process? 􀀀 􀀀 (2)
4.2 Is the process regularly reviewed to ensure follow up? 􀀀 􀀀 (1)
4.3 Is the safety and health committee involved in the process? 􀀀 􀀀 (1)
4.4 Is there a documented program for regular inspection of all plant and equipment? 􀀀 􀀀 (2)
4.5 Is there a documented system to record Job Safety Analysis 􀀀 􀀀 (2)
Marks obtained out of 8

5. Provision of Information
5.1 Are the activities of the safety & health committee communicated to the workforce? 􀀀 􀀀(1)
5.2 Are changes to work practices and procedures made known to the workforce? 􀀀 􀀀 (2)
5.3 Are changes to legislation, regulations, codes of practice, guidelines, etc, communicated to the workforce? 􀀀 􀀀 (2)
Marks obtained out of 5

6. Induction/Training Yes No Mark
6.1 Is an induction program in place? 􀀀 􀀀 (1)
6.2 Is there an on the job documented training program? 􀀀 􀀀 (1)
6.3 Are individual records of training maintained? 􀀀 􀀀 (1)
6.4 Is there a continuing training program for supervisors? 􀀀 􀀀 (1)
Marks obtained out of 5

7. Personal Protective Equipment
7.1 Have all employees been instructed in the correct
usage and maintenance of PPE? 􀀀 􀀀 (2)
7.2 Are all forms of PPE available at all times? 􀀀 􀀀 (1)
Marks obtained out of 3

8. Hazardous Materials
8.1 Is there a hazardous materials management system in place? 􀀀 􀀀 (2)
8.2 Is it updated and maintained regularly? 􀀀 􀀀 (1)
8.3 Is it freely available to safety & health representatives? 􀀀 􀀀 (1)
8.4 Is all the required signage current and in place? 􀀀 􀀀 (2)
Marks obtained out of 6

9. Incident Reporting and Investigation
9.1 Are the requirements for reporting all accidents, incidences and near misses known to all employees? 􀀀 􀀀 (2)
9.2 Are the requirements complied with? 􀀀 􀀀 (1)
9.3 Is there a documented procedure for investigation of all such accidents, incidences and near misses? 􀀀 􀀀 (1)
9.4 Are the results of these investigations and corrective actions conveyed to all employees? (1)
9.5 Are written records of all accidents, incidences & near misses maintained? 􀀀 􀀀 (1)
9.6 Is there a program for regular workplace inspections by senior management? 􀀀 􀀀 (2)
Marks obtained out of 8

10. Emergency Planning and Response
10.1 Is there documented emergency response plan? 􀀀 􀀀 (1)
10.2 Is the plan regularly tested and reviewed? 􀀀 􀀀 (2)
10.3 Is all emergency equipment available and maintained? 􀀀 􀀀 (2)
Marks obtained out of 5

11. Medical Treatment and Rehabilitation
11.1 Are trained first aid services available at all times? 􀀀 􀀀 (1)
11.2 Is there a procedure in place for medical treatment and/or evacuation of injured personnel? (1)
11.3 Is there a substance abuse procedure in place? 􀀀 􀀀 (1)
11.4 Is there a documented program for rehabilitation and return to workof injured personnel? (1)
Marks obtained out of 4

12. Certification
The above information is an accurate evaluation of the organisation’s Health and Safety Management
Sub Contractor Company:
Signed: Date:
Position:

OFFICE USE ONLY
TOTAL / 64 RESULT……………… % ACTION :