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FRM-QAL-0010
Revision No: 6
Date: 18/02/2012
SUPPLIER EVALUATION QUESTIONNAIRE
Section 7.
Health, Safety and Environment-
TO BE COMPLETED BY SUBCONTRACTORS ONLY.
Yes
No
N/A
1
Does your Company have a documented Safety Management System and Safety policy?
2
Does your Company have a Safety Induction Process in place?
3
Has all of your site staff completed the mandatory blue/white card?
If Yes, please ensure a copy is provided to the FGL site supervisor prior to commencement.
4
Does your company ensure that all employees undergo a pre-employment medical to deem they are fit
for work?
5
Are employees trained and involved in processes that identify hazards on the job at the start of each day
or task?
6
Are Safe Work Method Statements (SWMS) / Job Safety Analyses (JSA) developed and communicated for
all work activities?
If Yes, attach a copy of a SWMS / JHA for the proposed works.
7
Are relevant licenses, training and competency assessments to operate plant or equipment or perform
high risk work checked prior to commencement of the work activity?
If Yes, please ensure copies are provided to the FGL site supervisor prior to commencement.
8
Will you being using Hazardous Substances to carry out tasks on site?
If Yes, please ensure a copy of the relevant Material Date Safety Sheets (MSDS) is provided to the FGL
site supervisor prior to commencement.
9
Are on-going maintenance and inspection of machinery and equipment in place, as per statutory
inspection requirements.
10
Is all electrical equipment proposed for the works tagged and maintained?
11
Have you been issued with any prohibition/improvement notices or a safety offence within the last 3
years?
If Yes, please provide details
12
Do you have a system for the recording of safety performance statistics?
If Yes, please complete table below
Last Year
Year Before Last
2 Years Before Last
Provide the following Safety Statistics for the last three
years (refer AS1885.1).
Total Man-hours worked for each period
No. of Lost Time Injuries
Lost Time Injury Frequency Rate
No. of Medical Treatments
Medical Treatment Frequency Rate
1. Lost Time Injury Frequency Rate (LTIFR) - is the rate of all Lost Time Injuries (LTI) for each 1,000,000 hours worked over a 12 month period.
LTIFR =
(LTI ‘s)
x
1,000,000
No# of hrs worked
2. Medical Treatment Injury Frequency Rate (MTIFR) - is the rate of all Medical Treated Injuries (MTI) (ie Any workplace injury that has resulted
in the person requiring medical treatment from a practicing GP however does not result in a full working day lost from the injury) for each
1,000,000 hours worked over a 12 month period.
MTIFR =
(MTI‘s)
x
1,000,000
No# of hrs worked
Process Owner: D. Gordon
Intranet version is current, copies are uncontrolled documents
Process Author: N.DiCarlantonio
Page 5 of 6
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