Attachment No. 2 to SD-09.01.

21

HSE
Qualification Questionnaire No. _________

This evaluation is used by the Company (NIS j.s.c. Novi Sad), in order to determine to what extent a
Contractor meets the HSE* criteria for safe and environmentally friendly conduct in its business activities.
The Questionnaire consists of a wide range of questions pertaining to HSE, and based on responses, the
Company will assess whether such Contractor will be qualified and given the status of “HSE Qualified
Contractor”. Legal requirements concerning Occupational Health and Safety (OHS), Environmental
Protection (EP) and Fire Protection (FP) are a mandatory minimum.
1. Contractor’s details
Full name of the Contractor’s company:___Eco steam_________________________________________
Full address: _______________________________________________________________________
Registration No. 64372688 ________________ TIN: __109708827________________
Core activity: Building and equipment cleaning Activity code: 8122_____________________
Contact person: _ Nešić Saša_________________ Position: Managing director_________
Telephone numbers: _____+3816364011______ e-mail: info@eco-steam.rs ___________________
The area of activity applied for **: Industrial floor cleaning and degreasing, Cleaning of central air
conditioning system ducts, Cleaning and degreasing - other
Indicate previous contracts with the Company specifying NIS j.s.c. Novi Sad reference numbers (if any)
____________________________________________________________
2. Profile of the Contractor’s company
2.1. Type of activities performed by the company – description of services
Cleaning of surfaces and equipment by machine _________________________________________
Cleaning and disinfection of space, machinery and equipment by steam _______________________
Cleaning and disinfection of space by dry steam__________________________________________
Cleaning and disinfection of oil contaminated surfaces and equipment _________________________
2.2. Details about the Company’s organization
Key positions Information on existence / number
of employees
Management 1
Line managers (Heads/supervisors) 1
Employees
The total number of employees in the company 2
Engaged third parties No
Job classification / extract from job classification – Job Cleaning with industrial machines
description using steam
Decision on the appointment of the Occupational Health and
Yes
Safety Officer (photocopy)
The total number of working hours of the employees
176/1936
(monthly/annual)

2.3. Structure of injuries in the company

Injuries/illnesses in the past 12 months

Number
Fatalities 0
Disability-causing injuries 0
Lost time injuries (with lost days from work) 0
Injuries with medical treatment (without lost days from work) 0
Injuries without lost hours from work 0
Provide the evidence by attaching corresponding forms of OHS records (Form 3 or Form 4)
HSE* - Generally accepted abbreviation for: Health, Safety, Environment. A synonym for HSE activities in organizational units of the
Company is IEP OHS (Industrial and Environmental Protection, Occupational Health and Safety).

2.4. Requirements in accordance with a risk related to the contractor

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Attachment No. 2 to SD-09.01.21

** In order to recognize successfully the risk level of services that you provide to the Company, use the
attached table – Segmentation of services according to risk level with already identified risk levels for all
identified services.
Enter in the field: The area of activity that you apply for, all the activities that you have recognized in
the attached table.
If you provide several services, fill out the Questionnaire on the basis of the highest risk level, i.e. if you
apply for five activities three of which are low-risk activities and two are medium-risk activities, you shall
fill in and provide evidence required for medium-risk level, even if you are not applying now for a tender
for the provision of medium-risk services, but for the provision of low-risk services. The same analogy is
applicable in the case of services with a high level of risk.
Documents shall be submitted according to the table below:

Contractors applying for services Documents required in Table Documents required in Table Documents required in Table
classified as 2.5 2.6 2.7

can be submitted, but it is not can be submitted, but it is not

Low-risk Mandatory submission
mandatory mandatory

can be submitted, but it is not

Medium-risk Mandatory submission Mandatory submission
mandatory

High-risk Mandatory submission Mandatory submission Mandatory submission

2.5. MANDATORY DOCUMENTATION for ALL Contractors:

Question Yes/No Submit the following MANDATORY evidence:

Does your company have a Workplace
Risk Assessment Act (for foreign
1* companies: General Risk Assessment)?
Does your company have a mandatory
2* employee work injury compensation
insurance?
Do you keep Records required by the OHS
3* Record Keeping Regulation?
Do you have an Employee Training
4*
Program?
Have your company registered all the
5* employees with the Health Insurance
Fund?
Do you keep Records of fire-fighting
6*
training courses?
Do you keep Records of your employees
7* trained in First Aid?
Have your employees been given for use
8* the PPE defined in the Risk Assessment
Act?
Yes The Conclusion of the Risk Assessment Act (hereinafter referred
to as: RA Act), the page showing who is the owner of the RA Act,
the page showing who is the author of the RA Act, the page
showing when the RA Act was created, i.e. the last revision of the
document.
Yes Mandatory Work injury compensation insurance, together with the
list of employees.
Yes ALL records stipulated in the Regulation, duly signed by the
responsible person in your company (not applicable to foreign
companies)
Yes An employee training program with topics, i.e. activity areas for
which training courses are provided in you company.
Yes Submit M1 forms for employees who will be engaged during the
Contract period (not applicable to foreign companies).
Yes Submit records of completed mandatory fire-fighting training of the
employees.
Yes Submit records of completed mandatory training of your
employees in First Aid (for all supervising personnel + 2% of the
employees)
Yes Submit records of provided PPE, as well as the extract from the
Risk Assessment Act for the purpose of evidence control.

2.6. .For MEDIUM AND HIGH risk contractors:

Question Yes/No Submit as evidence:

Do you have Employee Training Program
9 by job position (Training Matrix)
Is there an adopted OHS (HSE) Rulebook
in you company
10
11 Do you possess ISO 9001 certificate (for
Yes Employee Training Program, i.e. Training Matrix by job position in
the sense that it clearly indicates which trainings are necessary for
each specific job position.
Yes OHS (HSE) Rulebook or other document that prescribes the
method of establishing occupational health and safety
management system, as well as Roles and Responsibilities of the
employees.
No Submit the valid certificate concerning the implemented standard

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Attachment No. 2 to SD-09.01.21

contractors handling food – HACCP)
Do you have a clearly defined HSE (OHS)
12
policy?
Is there a clearly defined Policy in you
13 company on alcohol and psychoactive
substance abuse?
Do you have the established Risk
14 Management System (Work Permits
system, immediate risk assessment)?
Do you have defined Operative
Procedures and Safe Work Instructions?
15
of quality assurance ISO 9001 or for contractors handling food the
HACCP standard.
Yes Submit a copy of HSE Policy, as well as an explanation of how it
has been presented to the employees in your company.
Yes Submit such Policy, Resolution or other document reflecting the
stance of your company regarding a ban on the use of alcohol or
other psychoactive substances and work under their influence.
Yes Submit a rulebook, procedures, standard regulating the manner in
which your company manages high-risk activities.
Yes Submit a list of operative procedures, which prescribe actions
when performing routine daily activities, a list of safe work
instructions, as well as the evidence that your employees are
familiar with procedures and instructions pertaining to their work.

Submission of four pieces of evidence (out of seven required), at Contractor’s choice, is the
minimum for positive evaluation. Additional points are given for each additional piece of evidence
(fifth, sixth…)
2.7. For HIGH risk contractors:

Question Yes/No Submit as evidence:

Do you have the established

contractor/subcontractor management Procedure for managing work of the hired Subcontractors
16 system (MANDATORY for Contractors
entering the job with their
Subcontractors)?
Do you have an established HSE (OHS) Example of the Minutes/Record of control of employees during
17 performance Monitoring System their performance of duties and tasks
(observations, supervisor walkarounds…)?
Have you implemented OHSAS 18001? Valid certificate for the implemented quality control standard
18 OHSAS 18001, as well as certificate of internal auditors for quality
system control by the employees
19 Have you implemented ISO 14001? Valid certificate of implemented quality control standard ISO 14001
Do you have the established system of Procedure for investigating HSE events
20
HSE incident investigation?
Does your company have the established Analysis of health status of the employees for the previous year
system for monitoring health of the
21
employees, focusing on identified hazards
and harms they may be exposed to?

22 Have you implemented any other ISO Valid certificate of implemented quality control standard
standard for quality control (27001,
50001,…)
23*
Does your company have an appointed Decision/resolution on the appointment of the responsible person
person in charge of waste management?

24* Does your company keep daily and annual Submit the required records (applicable only to the companies
records of the quantities of generated that generate waste during their operation)
waste?

25* Does your company have procedures for Procedures for management of waste and hazardous
management of waste and hazardous substances/chemicals?
substances/chemicals?
Have your employees performing works Evidence of training of the employees working with hazardous
26*
with hazardous waste or hazardous waste or hazardous substances/chemicals.
substances/chemicals been trained for
work with these substances?

Submission of three pieces of evidence (out of seven required, questions under Nos. 16-22), at
Contractor’s choice, is the minimum for positive evaluation. Additional points are given for each
additional piece of evidence (fourth, fifth, sixth…)
*Requirements from 23 through 26 are MANDATORY for the Contractors that have established quality
assurance system ISO 14001, as well as for the Contractors applying for activities in the area of
Environmental Protection (EP).
2.8. HSE Recognitions and Achievements of the company
HSE Recognitions / Achievements
State the main details about recognitions
Recognitions

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Attachment No. 2 to SD-09.01.21

Awards (to the company)

Awards (to the employees)
HSE Officer
Provide evidence by attaching appropriate elements/documents
3. Other important information
If you possess any other information that may help us in the process of evaluating your capabilities to work
efficiently from the HSE point of view, i.e. safely and environmentally friendly, please attach it as additional
documentation.

1.1. Other / Additional documentation Yes No

1.
2.
3.
4.
5. …
Supply evidence by attaching copies of records/documents
4. Occupational health and safety
Risk Assessment Act was issued on 15/03/2017 (enter the date using format dd.mm.yyyy)
Revision of the Risk Assessment Act was made on (is planned for) 15/03/2019. (dd.mm.yyyy)
Authorized/appointed OHS Officer __________________________________________
(state name, surname and ID number of the OHS Officer)

The successfully passed professional exam of practical training for performing OHS jobs.
_______________________________
(number of certificate, date of issuance)

State the members of the OHS Board (if any): _________________________________

(state name, surname and position)

_____________________________________ _________________________________
(state name, surname and position) (state name, surname and position)
_____________________________________ _________________________________
(state name, surname and position) (state name, surname and position)

5. Terms
All Contractors, Subcontractors and their employees must comply with HSE requirements of NIS j.s.c. Novi
Sad:
 HSE Policy;
 HSE Golden rules;
 Internal OHS, EP, FP rules;
 Requirements for managing undesired events with respect to OHS, EP and FP;
 Requirements of NIS j.s.c. Novi Sad internal standards;
 Rules for safe field / onsite work;
 Specific rules and requirements related to particular projects;
 Requirements and sanctions defined by the main HSE Annex.

As the representative of __________________________________________________________________,

(full name of the company as stated in the Decision of the Business Registers Agency - APR)

I agree on behalf of the Contractor, as well as on behalf of all the employees of our Subcontractors, to
observe requirements/recommendations issued by NIS j.s.c. Novi Sad. The Company NIS j.s.c. Novi Sad
shall not bear responsibility for incidents and accidents that may occur during activities of
Contracts/Subcontractors.
Signed for and on behalf of Contractor:
Full name and surname of the Contractor’s Representative: _____________________________

Signature: ______________________________

Date: ____ ____ _____ (dd/mm/yyyy)

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Attachment No. 2 to SD-09.01.21

*Note: Fields to be filled in by Procurement Administrator and the HSE Officer, i.e. responsible person at NIS j.s.c. Novi Sad,
with the aim of acknowledging the completeness and validity of documentation from the HSE point of view.

Opinion on the documentation submitted by the potential Supplier*

Лице за HSE

_________________________________________
(функција, име и презиме – (читко, штампано), потпис))
Note/comment*

Responsible person of NIS j.s.c. Novi Sad

______________________________________

(position, name and surname,– (in legible block letters, signature))

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Attachment No. 2 to SD-09.01.21

Distribution list:
1. Procurement expert
2. Contractor’s Supervisor
3. HSE Officer
4. Archive

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