SIEMENS

Supplier EHS Prequalification Questionnaire

Statements about The Supplier
Contractor name: PT. Weebz Mandiri
Service provided:
Address: Jl. Kartini VIII No.9 Kartini , Sawah Besar , Jakarta Pusat
Tel: +62.21.8838.0008 Fax: +62.21.8838.0007 E-mail: sales@weebzmandiri.com
Number of employee
supporting Siemens Total number of permanent staff employed:
operation: 12 people 25 people
Completed by: Zen Bintang Date submitted: 24 January 2018 Tel/e-mail: zen.bintang@weebzmandiri.com
Contractor key personnel:This is the person who has authority to response the request from Siemens and be the contact person between Siemens and your company
position/function Name Phone/Fax/e-mail

Managing Director Ruben Lalamentik 08118888662

Business Development manager Arri Kharloza 0811864760
Business Development Executive Zen Bintang 08161912632
Automation Engineer Setyo 081282598925

SUPPLIER / VENDOR AUDIT QUESTIONNAIRE

Certified system (x) Certification(s) Status: Section Rating Performance

ISO9001:2008 Certified by…………………...in year…. …….

ISO14001:2004 Certified by…………………...in year…. …….

Fixed weight (by section)

Significant Deficiency
OHSAS18001:2007 Certified by…………………...in year…. …….

Improvement Need
ISO50001:2011 Certified by…………………...in year…. …….

Satisfactory

Very Good
Good
I EC Ex 60079-19 Certified by…………………...in year…. …….
Reason for Assessment Audit Status:

Selection X Pre-qualification

X Evaluation Audit

Re-audit

Section <50 <70 <80 <90 100

Sec. Assessment Criteria Weighted score 0 50 70 80 90
1 EHS Policy, Organization and Responsibilities 0.00 15
2 EHS regulatory compliance and communication 0.00 10
3 EHS Risk Assessment and EHS safety plan/ procedures 0.00 15
4 EHS Training ,Work Competency 0.00 10
5 Medical service and EHS hygiene 0.00 8
6 Personal Protective Equipment 0.00 8
7 EHS Inspection, Audit and meeting 0.00 8
8 0.00 8
Substance Abuse Control / Waste Management/Hazardous Materials

9 0.00 8
Emergency Preparedness

10 0.00 10
Incident/Accident Reporting/ Prevention and Investigation Program

OVERALL RATING PERFORMANCE 0.00 100

OVERALL RATING COMMENT

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 Supplier Rating Guidelines
A supplier’s suitability for Siemens is evaluated on the basis of how well a supplier meets the selection criteria. The enclosed Management System Questionnaire is used as the basis for
evaluation. All subsections' case specific questions are selected and their weights are defined by PT Siemens Indonesia. PT Siemens Indonesia recommends that the supplier will carry
out a self assessment based on this questionnaire and attach the evidence for further verification from PT Siemens Indonesia. At each section, supplier with rating
performance below 50 will be knocked out and rejected.

Significantly Deficient 0 No guideline/procedure is adequately available but not implemented.

Improvement Needed 1 Guideline/procedure is adequately available but not implemented.

Satisfactory/Marginal Deficient 2 Guideline/procedure is adequately available and partially implemented.

Good 3 A well-designed guideline/procedure that reflects on actual implementation.

Effective implementation with monitoring system. Documentation and data existing to

Very Good 4 demonstrate control and continuous improvement.
Not assessed/not suitable for assessment. This does not effect the total number of
Not Applicable N/A points or the result of the audit.

Final Rating Matrix

The following tables should be used to determine the final score and overall rating performance of the supplier. The audit format and scoring are based on PTSI requirements.

Rating Performance: Supplier's Approval Status: Group

90 to 100 Very Good Approved by PTSI A

80 to 89 Good Approved by PTSI
B
70 to 79 Satisfactory Approved by PTSI
50 to 69 Improvement Need Repeat Audit (with justification) C

0 to 49

Or any criteria Unacceptable Deficiency Rejected by PTSI D

is rated < 50%

1.0 EHS Policy, Organization and Responsibilities Subsystem Ratings

Weight

Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does the contractor set an EHS Policy,objective an target (EHS program)?

1 1 0 Yes, we do. We have QHSE Policy, we attached
the EHS policy
Has the contractor set up a safety committee or similar organization in line with Thai
2
law? please provide details of representatives (i.e. position in the organization).
1 0 Yes, We have Safety Organization

Does the Contractor has staff members/organization that are officially designated and
3 responsible for overall EHS related matters at project site or branch office? 1 0 Yes, We do

Are EHS rules or EHS manual or EHS operating procedures/instructions and

4 responsibilities clearly defined in the Contractor’s organization?Is the system certified
to international standard (OHSAS 18001, ISO 14001)?
1 0 No,

Does the contractor aware of the Siemens EHS clause? What is the expected
5
service level to align with Siemens EHS clause
1 0 No, We Dont

Total Points 0

Section Rating Performance (Total points/Available Points) 0%

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 2.0 EHS regulatory compliance and communication Subsystem Ratings

Weight
Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

1 Has contractor identified applicable EHS legal requirements pertaining to work? 1 0

Does contractor has a system to record, review and communicate these legal
2
requirements to all relevant employees in organization?
1 0

3 Has the contractor complied to all applicable EHS legl requirements? 1 0

Total Points 0

Section Rating Performance (Total points/Available Points) 0%

3.0 EHS Risk Assessment and EHS safety plan/ procedures Subsystem Ratings

Weight
Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does the Contractor have procedures for hazard identification, risk assessment and
1 EHS risk management? 1 0

Does the Contractor ensure that all personnel involved in the particular work task are
informed of the EHS hazards and the risk management measures to be
2 implemented? please attach supporting documentation to explain scope, and 1 0
frequency and method of review and revision.

Does the Contractor have and enforce a permit to work system based on level of the
risk?
3 1 0

Are ‘toolbox meetings’ or pre-work briefings conducted prior to starting new on-site
4
work activities? Are minutes of tollbox meeting/pre-work briefings recorded? 1 0

Total Points 0

Section Rating Performance (Total points/Available Points) 0%

4.0 EHS Training ,Work Competency Subsystem Ratings

Weight

Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does Contractor’s employee have adequate

competency to perform their work (i.e. welding, grinding, crane operating, chemical
handling, electrical commissioning)?
1 1 0
Please provide sample of contractor’s personnel training record, certificates, and
experience, etc.

Have Contractor’s personnel been adequately

trained to perform their assigned EHS
responsibilities?
2 1 0
Please provide supporting documentary evidence of training programs, including new
staff inductions, EHS training course topics, frequency of refresher training, etc.

3 Are the record of training being maintained and compared with requirement by law? 1 0

Total Points 0
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 Section Rating Performance (Total points/Available Points) 0%

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 5.0 Medical service and EHS hygiene Subsystem Ratings

Weight
Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does Contractor’s employee undergo a pre-employment medical check, and annual

1
medical examinations throughout the term of their employment?
1 0

Are the Contractor’s first aid and/or medical treatment facilities maintained as per
2
Thai law?
1 0

3 Are Contractor’s employees trained in First Aid? If yes, please state how many. 1 0

Are the available medical facilities (Contractor’s and third party) adequate to cover
4 the number of employees and the type of foreseeable medical situations associated 1 0
with the Contractor’s activities and exposure?

At site, does contractor provide sufficient sanitation facilities,clean drinking water or

5
temporary housing for employee?
1 0

Total Points 0

Section Rating Performance (Total points/Available Points) 0%

6.0 Personal Protective Equipment Subsystem Ratings

Weight

Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Based on hazard and risk of each activity,does the Contractor provide sufficient and
1
suitable PPE for employee?
1 0

2 Are Contractor’s employee completely trained/instructed in the use of PPE? 1 0

3 Does the Contractor strictly enforce the proper use of PPE? 1 0

4 Are PPE regularly inspected and maintained? 1 0

Total Points 0

Section Rating Performance (Total points/Available Points) 0%

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 7.0 EHS Inspection, Audit and meeting Subsystem Ratings

Weight
Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does the Contractor follow a plan to conduct regular EHS audits, inspections and
review of its activities at site/facilities?
1 1 0

Are audits/inspections/review results documented and corrective action requests

2
issued and followed up?
1 0

Does the Contractor ensure that all resources (equipment, chemicals, etc) used in
3 the conduct of the work are fit for purpose and in good condition, and that personnel 1 0
are trained in the correct use of resources?
Does the Contractor have a program for regular audit and review of the permit to
work system to ensure its effectiveness?
4 1 0

Total Points 0
Section Rating Performance (Total points/Available Points) 0%
8.0 Hazardous chemical & material control/ Pollution & Waste Subsystem Ratings
Management

Weight
Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does the Contractor have procedures and/or instructions for the proper identification,
1
storage, handling, and transportation of hazardous materials/chemical?
1 0

Does the Contractor have procedures and/or instructions for the proper identification
2 and management system of the generated pollution/ hazardous-non hazardous 1 0
waste?

Does the Contractor maintain on-site copies of Material Safety Data Sheets for all of
3
its hazardous substances?
1 0

Are Contractor’s personnel trained in the proper handling of hazardous materials and
4
emergency response?
1 0

Does the Contractor have a Policy and Program for Substance Abuse control?
5 1 0

Does the Contractor have and enforce instructions or procedures for control of
6 restricted and prohibited substances? 1 0

Total Points 0
Section Rating Performance (Total points/Available Points) 0%

9.0 Emergency Preparedness Subsystem Ratings

Weight

Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Has the Contractor identified potential emergency scenarios and prepared

1
emergency response plans to address these at all of operations/sites?
1 0

Does the Contractor have adequate and appropriate emergency response equipment
2 (i.e. spill clean-up equipment, fire fighting equipment, emergency evacuation 1 0
resources)?

Are Contractor’s personnel trained in emergency response procedures and the use of
3
emergency response equipment?
1 0

Does the Contractor conduct regular emergency response drills and exercises
4
involving Contractor’s personnel?
1 0
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 Total Points 0
Section Rating Performance (Total points/Available Points) 0%
10.0 Incident/Accident Reporting/ Prevention and Investigation Subsystem Ratings
Program

Weight
Scored (0-4,
Description/ Examples of Evidence to be Verified.
N/A)

No. Description

Does the Contractor have a program for reporting and analysis of EHS accidents/
1
incidents /high potential incidents, hazard observation?
1 0

Does the reporting procedure cover:

1. Fatal accident
2. Lost Time Accident (LTA)?
3. Loss Time Day (LTD)?
2 4. Medical treatment case? 1 0
5. Restricted work injury?
6. First Aid case?
7. Near miss?
8. Damage or impact to environment/property/assets?
Does the Contractor ensure that root causes are identified, preventive and corrective
actions are identified and implemented?
3 1 0

Does the Contractor maintain accident/ incident/ near miss records and statistics?
4 please provide statistics for the last 3 years. 1 0

Does the Contractor have an EHS performance incentive award scheme?

5 1 0

Total Points 0

Section Rating Performance (Total points/Available Points) 0%

Supplier's Acknowledgement Reviewed by Siemens EHS manager Acknowledged by Siemens Project manager

Name: Name: Name:

Sign: Sign: Sign:
Contact: Contact: Contact:

END

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