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HSE AUDIT QUESTIONNAIRE

AIR LIQUIDE project reference:

Name of AIR LIQUIDE auditor: Audit date:

1 COMPANY IDENTIFICATION / PERFORMANCE IN TERMS OF SAFETY

Company name:.

CEO’s name: Phone:

Name of Health/Safety/Environment Manager: Phone:

Company address:

Company activities:

Company workforce:

% part-time staff:

Performance in terms of SAFETY over the past 4 years:

2016 2017 2018 2019

No. hours worked

No. near-accidents

No. accidents that did not interrupt work

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HSE AUDIT QUESTIONNAIRE

No. accidents that interrupted work

Lost time due to injury

No. fatal accidents

Frequency rate of accidents that interrupted work

Accident severity rate

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HSE AUDIT QUESTIONNAIRE

Reserved for use by AIR LIQUIDE auditor

Check the box that matches your answer YES NO REASONS / OBSERVATIONS

2 HSE MANAGEMENT

2.1 Do you have a formalized HSE Policy? ☐ ☐ Attach a copy of the letter of commitment by the Management

2.2 Do you periodically check that those at the company are Date of most recent evaluation:
☐ ☐
aware of and understand the HSE policy? Specify comments:

2.3 Do you periodically collect and analyze HSE

performance as part of a management review? Date of most recent management review :
● Do you manage a typology of HSE incidents and ☐ ☐ Main type of accidents:
accidents? Main type of near-accidents:
● Do you manage a typology of HSE near-accidents?

2.4 Have you defined an HSE organization with a

☐ ☐ Provide HSE organizational diagram:
description of roles and responsibilities for HSE?

2.5 Have you appointed an HSE Supervisor attached to the Name of the HSE Supervisor:
☐ ☐
Management? How long position has existed::

2.6 Do you have an HSE management system based on an

international standard (OHSAS 18000 or equivalent, ISO ☐ ☐ References of HSE standards:
14000, etc)?

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HSE AUDIT QUESTIONNAIRE

3 HSE MANAGEMENT SYSTEM

3.1 Do you have an HSE manual? ☐ ☐ Attach a copy of the HSE manual -

3.2 Do you have written procedures/instructions for:

3.2.1 Developing an HSE plan on a work site? ☐ ☐ Reference:

3.2.2 Managing and wearing protective equipment? ☐ ☐ Reference:

3.2.3 Licensing electricians? ☐ ☐ Reference:

3.2.4 Implementing work permits? ☐ ☐ Reference:

3.2.5 Loading/unloading operations? ☐ ☐ Reference:

3.2.6 Working in a confined area? ☐ ☐ Reference:

3.2.7 Markers and signage? ☐ ☐ Reference:

3.2.8 Installing and using scaffolding? ☐ ☐ Reference:

3.2.9 Handling chemical products? ☐ ☐ Reference:

3.2.10 Working high up? and individual authorization? ☐ ☐ Reference:

Reference:
3.2.11 Emergency intervention (first aid)? ☐ ☐
Number of first-aid workers:

3.2.12 Handling accidents / incidents / near-accidents? ☐ ☐ Reference:

3.2.13 Training staff in HSE? ☐ ☐ Reference:

3.2.14 Carrying out HSE audits on a work site? ☐ ☐ Reference:

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HSE AUDIT QUESTIONNAIRE

3.2.15 Managing safety indicators? ☐ ☐ Reference:

3.2.16 Managing waste and environmental protection? ☐ ☐ Reference:

3.3 Do you sanction employees if they fail to follow the

☐ ☐ Specify the consequences:
rules? (Memo, Suspension, Termination)

4 PROTECTIVE EQUIPMENT

4.1 Have you identified the individual protective equipment ☐ ☐ Attach a copy of the equipment list:
that is essential for your employees?

4.2 Have you identified the collective protective equipment ☐ ☐ Attach a copy of the equipment list:
that is essential for your employees?

4.3 Do you have written instructions for using work site ☐ ☐ Attach a copy of instructions:
equipment/tools?

4.4 Do you periodically train your employees on how to ☐ ☐ Date of the latest and the next exercise:
wear individual and collective protective equipment?

☐ ☐ Date of the latest and the next exercise:

4.5 Are your employees trained on how to put out fires?

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HSE AUDIT QUESTIONNAIRE

5 SUPERVISION OF SUBCONTRACTORS

5.1 Do you systematically pass along your Clients' HSE

☐ ☐ How?
requirements to your subcontractors?

5.2 Do you perform an HSE evaluation of your

☐ ☐ What are the criteria?
subcontractors at the end of a project?
5.3 During the performance of a contract, do you carry out
planned HSE audits and follow up with your Date of the most recent audit:
☐ ☐
subcontractors to evaluate the effectiveness of their Date of the latest follow-up:
HSE management system?
5.4 Do you sanction subcontractors who do not satisfy the
☐ ☐ How?
HSE requirements?
5.5 Do you ensure that your subcontractors have the
☐ ☐ How?
necessary HSE skills.
5.6 Do you provide HSE training for your subcontractors? ☐ ☐ If yes, attach a copy of the HSE training program
6 HSE TRAINING FOR COMPANY EMPLOYEES
6.1 Have you developed a training program based on the
risks related to your activities?
● For permanent staff? ☐ ☐
● For newly hired employees? ☐
☐
● For temporary employees?
☐ ☐
● For transferred employees?
☐ ☐

6.2 For each member of your staff, do you systematically

☐ ☐
record HSE training courses?

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HSE AUDIT QUESTIONNAIRE

7 SHOP SURVEY

7.1 Display of HSE Policy? ☐ ☐

7.2 Emergency Exit Plan is displayed? ☐ ☐

7.3 Exit Signage are displayed? ☐ ☐

7.4 Fire Protection System is available & Accessible? ☐ ☐

7.5 Hooter System is available & visible? ☐ ☐

7.6 Safe Working Load is displayed on Overhead cranes

☐ ☐
and Forklifts?

7.7 Yellow marking on the pathway? ☐ ☐

7.8 Gas Cylinder storage area is clearly identified and

☐ ☐
marked?

7.9 Uses of Personal Protective Equipment (Safety Shoes,

☐ ☐
Helmet, Gloves, Goggles, ear plugs etc. )

7.10 General Housekeeping, walkways are free of

☐ ☐
obstructions

7.11 Noise Pollution ☐ ☐

7.12 Emergency Phone numbers are displayed ☐ ☐

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HSE AUDIT QUESTIONNAIRE

8 AIR LIQUIDE ENGINEERING CONCLUSIONS YES NO SENSITIVE AREAS / COMMENTS / RECOMMENDATIONS

The audited company has a structured HSE management system that

covers all activities that must be implemented for a contract with AIR ☐ ☐
LIQUIDE ENGINEERING.

The AIR LIQUIDE ENGINEERING AUDITORS recommend that the

☐ ☐
audited company be qualified.

INDIVIDUALS CONTACTED POSITIONS VISA CONCLUSION BY POSITION VISA

E-TPL-17-0-6, Rev. D