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Cshp Form 1a-2023
Cshp Form 1a-2023
Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with
complete requirements and attachments will be processed.
Tel. No:
Fax No.
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)
Project Classification: Estimated No. of Workers to be Date of Estimated Start/Execution of the project:
deployed in the project:
Bank Protection Slope Collapse / /
Month Day Year
(Workforce of the project to
Total Project include workers of the sub- Duration of the project (Pls. state the number of
Cost: contractor/s) calendar days)
_______________________________
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
Department of labor and Employment FOR THE EVALUATION/PROCESSING OF
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.
2.
3.
4.
5.
(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:
Submitted By: