NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

Revised Form: CSHP Form 1A-2023:

Date of Revision: 30 April 2023 Page 1 of 3
APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Legal Bases: Type of Construction Project:
1. Presidential Decree No. 442, as renumbered √ DPWH project
2. Republic Act No. 11058 Other Public/private construction project
3. Department Order No. 198, Series of 2018
(LGUs, other gov’t offices, private entities)
Residential project engaging the services of
a construction firm
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR/SUBCONTRACTOR/BUILDING OWNER in applying for a Construction Safety and Health Program
intended for a specific construction project.

Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with
complete requirements and attachments will be processed.

A. Company Profile/License/Registration of Main/General Contractor

Complete Name of the Company/Main/ Complete Address of the Project
General Contractor/Project Owner
KM.12 Diversion Road, Panacan Davao City
VICENTE T. LAO
CONSTRUCTION
Tel. No: 264-0501
Fax No. 234057

Name of Project Manager/Owner/ Tel. No:

Contact Person: Email: vtlc.cuevasproject2022@yahoo.com
REYNALDO C. FERNANDEZ
Contractor’s PCAB/JV License No: Number of workers:
07040
Male: 11 Female: 4 Total employment: 1 5
Date of Validity: November 25, 2026
Engaged Subcontractors’ Profile

Name of Sub-contractors (If Scope of Work and No. of Workers PCAB Date of Date of DOLE
any) Project Cost License Validity Registration

1.
2.
3.
4.
5.
6.
7.
(Use separate sheet, if necessary)
 Department of Labor and Employment APPLICATION FORM
REGIONAL OFFICE NO. FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

B. Project Profile/Description
Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or other documents indicating name and details
of the project)

24NB0062 NRJ Bah-Bah-Talacogon Rd – K3133+(-1003)-K1311+(-607), K1311+(-574) –

K1311+(-501), K1311+(-217)-K1311+(-067), K1311+000-1311+520.24,
Talacogon Agusan del Sur.

Complete Project Address/Location:

TALACOGON, AGUSAN DEL SUR

Name of Project Owner: Tel. No: +63-822340501

DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS 1st Fax No: +63-822340557

DISTRICT ENGINEERING OFFICE REGION XIII
Email :

vtlc.cuevasproject2022@yahoo.com

Project Classification: Estimated No. of Workers to be Date of Estimated Start/Execution of the project:
deployed in the project:
Bank Protection Slope Collapse FEBRUARY / 08 / 2024
30 Workers Month Day Year

Total Project (Workforce of the project to Duration of the project (Pls. state the number of
Cost: Php 36,053,366.53 include workers of the sub- calendar days)
contractor/s) _______________________________

Calendar days
Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary)

Revised Form: CSHP Form 1A-2023 Page 2 of 3

 Name
Date of Revision: 30 April 2023 Date of Name Date of ID
training training Validity
APPLICATION FORM
Vivian
Department of labor and Employment 21-25,
D. Petines April PRINCESS V. RAGA February February
2024 FOR THE EVALUATION/PROCESSING
11, 2024 OF2026
10,
REGIONAL OFFICE NO. CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
OSH Personnel assigned to the project
Designated Safety Officers: Designated First Aider:

(Please attach photocopy of Certificate of Completion on the Basic Please attach a photocopy of the Certificate of First-
OSH Course for Construction Site Safety Officers issued by DOLE- Aid Training and valid First Aid ID from Phil Red Cross,
BWC accredited Safety Training Organizations or DOH, Bureau of Fire and DOLE- Accredited TVIs with
recognized institution) TESDA registered EMS and other DOLE-Accredited first
aid training
provider
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of required BOSH Training
OH Nurse
OH Physician
Dentist
(If Heavy Equipment will be used in the Project)
List of heavy equipment to be used in the Project: Name of Heavy Equipment Operator/s:
1. Backhoe 1.
2. Dump Truck 2.Clomohoy, Janrich
3. Transit Mixer 3.Dela Cerna, Arvin
4. 4.Bentoy, Erwin
5. 5.Jopia, Oliver
(Please attach additional sheet, if necessary.) (Attach photocopy of skills certification from TESDA.)
Profile of the person who prepared the CSH Program for the abovementioned
Project
Educational Background:
Bachelor of Science in Accountancy
Work Experience in OSH:
JOEVY B. HINOG Site Safety Officer
Other Qualifications:
Signature over printed name
I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULNESS OF THE ABOVEMENTIONED INFORMATION. THE
COMPANY HEREBY COMMITS TO STRICTLY IMPLEMENT THE ATTACHED CONSTRUCTION SAFETY AND
HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.

Submitted By:
JOEVY B. HINOG Safety Officer
Signature Over Printed Name of the Position Date
Owner/Contractor
Assigned Evaluator
I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON THE
DOLE PRESCRIBED CHECKLIST.
Evaluated By:

Signature Over Printed Name Position Date