Health, Safety and Environment Pre-Qualification Questionnaire

Health, Safety & Environmental Long Form Questionnaire

Version 1, August 2016 - FINAL

Contract Name: [insert name here]

Company Name: [insert name here]

Purpose of Questionnaire

The purpose of this questionnaire is to have a tool available for government agencies to assess the health, safety
and environmental capability of potential contractors. This document was developed to support procurement
teams of government agencies to assess the health, safety and wellness capabilities of contractors for medium to
large contractor projects or smaller projects where there is a risk of serious injury occurring. However, it can be
used to assess any contractors health, safety and environmental capability prior to their engagement. The intention
of the questionnaire is to determine if contracting companies have a robust health and safety management system
and to assess their application of that system in their contracting work. The use of this questionnaire will assist
Government agencies to align their work with the Government policy "Planning Construction Procurement". This
document can be found at http://www.business.govt.nz/procurement/pdf-library/agencies/construction-guidance/.

The document should be completed based on current undertaking and not what you would do in the future.

Assessment Advice

The assessment tool (second tab of this document) should be applied by an experienced Safety Specialist. To fully
assess this information their knowledge will need to include understanding hazardous substances (for questions in
section 7.7) and the environment and sustainability (for questions in section 15) or they will need to seek advice
from others with knowledge in those areas. Recommendations will be made to the Project Group based on the
assessment outcome. The Specialist will assess all the answers and information provided for each section and
score that individual section overall using the rating scale in the second tab. It is not a pass/fail situation.

If sections are not applicable they should not be scored. To ensure the contractor is not disadvantaged, the
specialist needs to take this into account with their overall end score.

In assessing the results, the specialist should look at the overall score and any low scores for any section. If there
are shortcomings in the capability of the contractor the Project Group can consider the provision of additional
resources if appropriate.

Please note that completion and assessment of this questionnaire does not constitute a full health and safety
assessment by the procurer.

Contractors completing this form

· Please forward evidence where requested with this document

· Please list the evidence you have attached at the end of this questionnaire (Section 17)
·         Note – Your responses will be evaluated by a competent Safety Specialist
Section 1 – Commitment & Leadership / Company Accreditation Yes No N/A

1.1 Do you have a documented health and safety policy, is it signed by your CEO, Managing
Y N
Director or similar and is it reviewed and/or updated on a regular basis?

1.1.2 Describe below how, and how often, the policy is communicated to workers (press Alt+Enter to
Y N
start a new line) :

1.1.3 Evidence - Please provide a copy of your current H&S Policy.

1.2 Describe below what your company leaders do to ensure safety is working within in your
company? (press Alt+Enter to start a new line)

1.2.1 Does your senior management team participate in safety observation tours, safety
Y N
conversations, safety walks or similar out on site?

1.3 Does your company have documented expectations of safety behaviours at all levels? Y N

1.4 Do you have a senior manager who is responsible for health and safety in your company? Y N

1.4.1 List their health and safety qualifications and/or experience below (press Alt+Enter to start a new
line)

1.5 Are you in the Workplace Safety Management Programme or the ACC Partnership Programme? Y N

1.6 Select the level of accreditation you hold in WSMP or ACCPP (click into the row and select from
the dropdown list) .

1.7 Are you accredited or a signatory to any other health and safety related programmes/certifications
Y N
e.g. SiteWise, PreQual, Canterbury Rebuild Safety Charter, ISO?

1.8 If yes, please provide details below (press Alt+Enter to start a new line):

1.9 Has your company ever received any health and safety related awards? Y N

1.10 If yes, please provide details below (press Alt+Enter to start a new line):

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

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Section 2 – Non-compliance Yes No N/A

2.1 Have you ever had any prohibition, infringement, improvement notices, written warnings, non- Y N
disturbance notice and an enforceable undertaking (under either the HSE Act or the HSWA Act, as
appropriate) from a regulatory body in the last three years? (Please note - historical notices may not
jeopardise your chances of gaining this contract. Focus however will be on your actions to improve
after the infringement)

2.1.1 If yes, please provide details below (press Alt+Enter to start a new line):

2.1.2 What did you do to rectify the issues relating to these notices / warnings? (press Alt+Enter to
Y N
start a new line):

2.2 Has the company been prosecuted for health and safety related breaches in the last three
Y N
years?

2.2.1 If yes, please provide details below (press Alt+Enter to start a new line) :

2.2.2 What did you do to rectify the issues relating to the prosecution? (press Alt+Enter to start a new
line)

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Section 3 – Planning and Continuous Improvement Yes No N/A

3.1 Does your company have any recent Health and Safety Improvement Plans (or similar) you are
Y N
working towards?

3.1.1 Evidence - Please provide copies of your latest improvement plans.

3.2 Can you indicate below how your company intends to consult, co-operate and coordinate with
other PCBUs related to this contract? (press Alt+Enter to start a new line):

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Page 3 of 13
Section 4 – Training and Supervision Yes No N/A

4.1 Do your workers receive any health and safety training prior to starting work? Y N

4.2 Does this training include the following information:

4.2.1 Safety principles and legislation Y N N/A

4.2.2 Hazard identification and the hierarchy of controls Y N N/A

4.2.3 The relevance of site inductions and site specific safety plans Y N N/A

4.2.4 High risk work activity and what safe looks like for relevant tasks Y N N/A

4.2.5 Promoting positive safety behaviour and culture Y N N/A

4.2.6 The consequences of poor health and safety practices Y N N/A

4.2.7 Knowledge assessment specific to the task e.g. roofer/scaffolder Y N N/A

4.3 Does your company identify training/qualification/supervision requirements for high risk work? Y N

4.4 If yes, please outline the specific training requirements for workers involved in high risk work
(press Alt+Enter to start a new line):

4.5 Evidence – Please provide copies of a training needs analysis or similar.

4.6 Does your company keep training records or operate a training register? Y N

4.7 Describe how you determine a worker is competent when performing high risk work? (press
Alt+Enter to start a new line):

4.8 If workers are inexperienced, describe how their safety is managed (press Alt+Enter to start a
new line):

4.9 Will there be a supervisor or similar responsible for health and safety on each of the work sites for
Y N
the duration of the contract?
Office Use Only
Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Page 4 of 13
Section 5 – Worker Engagement & Consultation Yes No N/A

5.1 Does your company operate a worker participation system that includes worker representation in
Y N
health and safety?

5.1.1 If yes, describe the main components of your system and how it operates (press Alt+Enter to
start a new line):

5.1.2 Evidence – Please provide copies of your worker participation system in action e.g. minutes of
committee meetings, safety rep elections. Please remove any names of people and/or their positions
from this information.
Office Use Only
Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Section 6 – Health & Safety Induction Yes No N/A

6.1 Does your company have a Health & Safety Induction Programme? Y N

6.1.1 Briefly describe the programme (press Alt+Enter to start a new line):

6.2 Does your induction programme extend to your construction sites? Y N N/A

6.2.1 Is the following information included in your site induction?

6.2.1.1 Use of a site Sign In / Sign Out Register or similar Y N N/A

6.2.1.2 Provision of information on the SSSP, site hazards, controls and/or what to do to eliminate or Y N N/A
minimise any risk, and site rules

6.2.1.3 Procedures for task analysis (or similar) and reporting of all accidents and near misses Y N N/A

6.2.1.4 Requirement to report medical conditions that may impact workers or any other persons on site Y N N/A

6.2.1.5 Overview of the site emergency response plan and first aid facilities Y N N/A

6.2.1.6 Relevant safety plans / method statements for hazards brought onto the site by any person Y N N/A

6.2.2 Evidence – Please provide copies of recent worker induction records, site entry registers or
similar. Please remove any names of people and/or their positions from this information

6.3 Describe how you manage visitors when they attend site (press Alt+Enter to start a new line):

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

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Section 7 - Risk / Hazard Management / Site Safety Risks / PPE Yes No N/A

7.1 Describe how hazards/risks are identified, assessed and managed in your company? (press
Alt+Enter to start a new line):

7.1.1 Describe how you involve your workers in identifying hazards and assessing risks (press
Alt+Enter to start a new line):

7.2 Describe how you provide workers with the highest level of protection (press Alt+Enter to start a
new line):

7.3 Does the company have a method for preparing and approving a health and safety plan such as
Y N
a SSSP, risk assessment, task analysis, job safety analysis etc.

7.3.1 Evidence – Please provide copies of recently completed hazard management documents i.e.
SSSP, Risk Assessment, Hazard Register, SOPs, TAs, JSAs, PTW.

7.4 Does your company have a Hazard or Risk Register, or similar? Y N

7.4.1 Evidence – Please provide copies of your most recent Hazard or Risk Register.

7.5 Is there a system for identifying new hazards / risks? Y N

7.6 Describe how you determine the minimum PPE requirements for your work sites? (press
Alt+Enter to start a new line)

7.7 Does your company have a Hazardous Substance Register, or similar? Y N N/A

7.7.1 Are Safety Data Sheets relating to your substances available to your workers? Y N N/A

7.7.2 Evidence – Please provide copies of your most recent Hazardous Substance Register.

7.7.3 Are test certificates current for required sites? Y N N/A

7.7.4 Are there Approved Handlers for hazardous substances (where required)? Y N N/A

7.7.5 Indicate below how often the controls in your Registers (Risk and Hazardous Substances) are
evaluated for effectiveness and updated (press Alt+Enter to start a new line) :

7.8 Describe the maintenance/inspection programmes relating to your company mobile plant and
equipment, power tools and other electrical equipment (press Alt+Enter to start a new line):

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7.8.1 Do you have records indicating the maintenance / inspection systems are implemented and up to
Y N
date?

7.9 Do you have regular site meetings (Toolbox Talks or similar) where information on safe working
Y N
methods is shared?

7.9.1 Evidence – Please provide copies of two to four recent site meetings. Please remove any names
of people and/or their positions from this information.

7.10 Please outline details of your Occupational health programme (identified health risks, related
medical testing regime, schedule of testing etc.) (press Alt+Enter to start a new line):

7.10.1 Describe your company's Occupational Health Monitoring Programme, if health risks identified
(press Alt+Enter to start a new line):

7.11 Please outline how you will consult, co-ordinate and cooperate with others who have the ability to
influence or control risks on site (press Alt+Enter to start a new line):

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Section 8 - Critical Risks Yes No N/A

8.1 Briefly describe how the company manages the following risks (if applicable) e.g. Training, SOPs,
Task Analysis, PTW, etc. (press Alt+Enter to start a new line)
• Exposure to asbestos and other airborne risks
• Fall from heights
• Confined or restricted space
• Electric shock
• Mobile plant and machinery
• Excavation
• Hot work
• Workplace violence
• Traffic / pedestrians
• Other (please specify)

8.2 Describe how your (sub) contractors will manage those risks as well (press Alt+Enter to start a
new line) :

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

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Section 9 - Impairment Yes No N/A

9.1 Does your company have a Drug & Alcohol Policy? Please provide a copy. Y N

9.1.1 Does your Drug & Alcohol Policy include the following:

9.1.1.1 A commitment to promote a work environment free from drugs and alcohol Y N N/A

9.1.1.2 A programme for worker pre-employment, post incident and reasonable cause drug and alcohol Y N N/A
testing

9.1.1.3 Provision to remove anyone from the worksite deemed `unfit for work’ or `under the influence’, or Y N N/A
where the presence of drugs or alcohol exceeds accepted standards

9.1.1.4 Provision of drug and alcohol support and rehabilitation assistance for workers where Y N N/A
appropriate

9.1.1.5 A programme to raise awareness and provide training about the potential harmful effects of Y N N/A
drugs and alcohol in the workplace

9.2 Does your company have a Fatigue Policy or Fatigue Management Plan? Please provide a copy. Y N N/A

9.2.1 Does your Fatigue Policy or Management Plan include the following:

9.2.1.1 Recognition of fatigue as a hazard Y N N/A

9.2.1.2 Identification of possible work design risks e.g. long hours, stress Y N N/A

9.2.1.3 Identify where fatigue related impairment may cause safety risks e.g. driving, critical risk tasks Y N N/A
such as electrical

9.2.1.4 Requirement to provide resources e.g. posters, toolbox talk hand-outs on fatigue management Y N N/A

9.2.1.5 Provision of appropriate counselling services Y N N/A

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Section 10 - Emergency Response Yes No N/A

10.1 Do you have emergency procedures for the offices you occupy i.e. approved evacuation plans,
Y N
plans for other emergencies e.g. earthquakes, tsunami, severe weather?

10.2 Do you have emergency procedures for the construction sites your workers work from? Y N

10.3 Do the above plans identify the responsibilities of those involved? Y N

10.4 Evidence – Copies of plans for offices and sites.

10.5 Do staff receive training in the emergency response plans? Y N

10.6 Does your company conduct regular drills to test for compliance? Y N

10.7 Do you have qualified first aiders? Y N

10.8 Do you have first aid kits and fire extinguishers in company vehicles or on worksites? Y N

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

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Section 11 – Incident Management / Reporting Yes No N/A

11.1 Briefly describe the incident reporting process for your company (press Alt+Enter to start a new
line):

11.1.1 Select which are required to be reported in your company:

Incidents Accidents Injuries Near Misses/Hits Property Damage Hazards

11.1.2 Evidence – Copies of recently completed incident reports. Please remove any names of people
and/or their positions from this information.

11.2 Are incidents investigated within your company? Y N

11.2.1 Describe to what level (press Alt+Enter to start a new line):

11.3 Describe how recommendations / corrective actions resulting from the investigations are
managed and communicated (press Alt+Enter to start a new line):

11.4 Outline the types of incidents that are required to be reported to your Senior Leadership Team
(press Alt+Enter to start a new line):

11.5 Does your company regularly collate and analyse incident / injury or near miss data? Y N

11.6 If a notifiable event occurs who is responsible for notifying the Regulator? (press Alt+Enter to
start a new line)

11.7 Evidence – please provide numbers for the following incident categories for the last three years?

• Fatalities/serious harm to workers, contractors, sub-contractors to whom you

had a duty as a PCBU

• Lost time injuries, medical treatment injuries

• Incidents resulting in environmental damage or pollution

• Serious incidents involving property damage

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

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Section 12 – Sub-contractor Management Yes No N/A

12.1 Will you be using sub-contractors for this project? Y N

12.2 List the names of the contracting companies you intend to use in this project and the work you
N/A
will use them for (press Alt+Enter to start a new line):

12.3 Do you have a pre-qualification system that you will apply if you take on sub-contractors for this
Y N
work?

12.4 Briefly describe your pre-qualification system (press Alt+Enter to start a new line): N/A

12.5 Describe how you will determine if any sub-contractors you use are competent for the work they
will do and how they will work safely? (press Alt+Enter to start a new line)

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Section 13 – Measuring H&S Performance (Monitoring, Auditing) Yes No N/A

13.1 Does your company have a regular (e.g. weekly) site monitoring or inspection programme in
Y N
relation to your workers, contractors or sub-contractors safety?

13.1.1 Briefly describe this programme (press Alt+Enter to start a new line)

13.1.2 Evidence – Copies of two to three of your most recently completed monitoring or inspection
reports / checklists.

13.2 Describe how health and safety performance is assessed in your company e.g. audits,
inspections, TRIFR? (press Alt+Enter to start a new line):

13.2.1 Evidence – Copies of recently completed audits.

13.3 Are there recommendations or corrective actions that result from the audits? Y N N/A

13.3.1 Describe how the recommendations or corrective actions are managed (press Alt+Enter to start
a new line):

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Page 10 of 13
Section 14 - Worker Health & Wellbeing Yes No N/A

14.1 Does your company provide an injury management programme for your workers? Y N

14.2 Does it have procedures, roles and responsibilities documented for injury management? Y N

14.3 Does your company provide a health and wellness programme for your workers? Y N

14.4 Describe examples of your Wellness Programme:

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Section 15 - Environmental and Sustainability Yes No N/A

15.1 Do you have an environmental / sustainability policy? Y N

15.2 Environmental Sustainability - Briefly describe the measures you take to contribute to
environmental sustainability - in general and in relation to the RFP (press Alt+Enter to start a new line):

15.3 Goods & Services - Briefly describe any environmental sustainability elements in the goods or
services that you deliver (press Alt+Enter to start a new line):

15.4 Have you ever had to implement an environmental management plan. Explain below how you
Y N
monitored the plan (press Alt+Enter to start a new line):

15.5 Have you ever received environmental / sustainability awards? If yes please provide details
Y N
(press Alt+Enter to start a new line):

15.6 Have you ever received an environmental fine / prosecution? If yes, please provide details (press
Y N
Alt+Enter to start a new line):

15.7 Have you have been audited for your environmental management system? Please provide details
Y N
(press Alt+Enter to start a new line):

15.8 Are your products made using recycled materials? If yes, please provide details e.g. products,
Y N
materials and % content (press Alt+Enter to start a new line):

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15.9 Can a buyer return packaging / product parts to you for recycling? If not, please explain why
Y N
below (press Alt+Enter to start a new line):

Office Use Only

Section Weighted Value 5.5
Scoring Guide: Score 0-10 based on the Rating Scale in the Assessment Tool Tab Score 0

Page 12 of 13
Section 16 – Referees.  Please provide the names and contact details of three referees (clients you have provided services to 
within the last 24 months) that you are happy for us to contact.

Section 17 - Evidence. List the evidence you have attached in support of your application.

Section 18 - This information has been completed by the following person:

Name:

Company:

Position:

Date:

Digital
Signature:

Page 13 of 13