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Contractor HSE Profile Form

This document contains a contractor HSE profile form requesting information about a contractor's health, safety, and environmental profile, including injury/illness experience data, records of inspections by authorities, environmental penalties or fines, reports of hazardous spills, the contractor's HSE program and inspection procedures. It will be used to evaluate the contractor's HSE qualifications for a tender.

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188 views2 pages

Contractor HSE Profile Form

This document contains a contractor HSE profile form requesting information about a contractor's health, safety, and environmental profile, including injury/illness experience data, records of inspections by authorities, environmental penalties or fines, reports of hazardous spills, the contractor's HSE program and inspection procedures. It will be used to evaluate the contractor's HSE qualifications for a tender.

Uploaded by

ebyjoy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Attachment 2: Contractor HSE Profile Form

TENDER No. QAL-TEC-0060-20

HSE Requirements – Part 2


Contractor HSE Profile Form

Company:
Address:
Phone:

Name Telephone
Primary Contact
On-Site Supervision
Field Safety & Health
Representative

1. Provide your injury/illness experience data below.

Year Lost Time Occupational


Hours Fatalities Medical Days Lost
Injuries Illnesses
Worked treatments
2016
2017
2018

2. Have authorities (MIC, QP, and Ministry) inspected your company in the last 5 years?
Yes__No __
If yes, please attach a separate sheet for each inspection that includes this information:
 Date of inspection(s)
 Reason for inspection (employee complaint, routine, accident investigation)
 Number and classification of citations

3 Has any environmental inspector inspected your company in the last 5 years?
Yes ____ No ____
 Date of inspection(s)
 Reason for inspection (employee complaint, routine, accident investigation)
 Number and classification of citations

4. List all of the environmental penalties, fines, notice of violations and consent orders that your
firm has incurred in the last 5 years.

5. List all reportable hazardous substance/oil spills that you experienced on the job in the last 5
years.

6. Attach copy of your HSE program Table of Contents.

7. Specify the frequency of job site HSE meetings (weekly, monthly, and other).
______________________ please include a copy of a safety and health meeting report.

6. Specify how often job site HSE and housekeeping inspections are conducted and documented
(weekly, monthly, other). __________________ please include a copy of a recent inspection
report.

7. Specify how often your field HSE representative will visit the job site (weekly, monthly, and
other)? _________________

8. The undersigned warrants and represents the data provided in these documents accurate in all
respects.

Name: ______________________________Title:________________________________

Signature: ________________________________Date:_____________________________
Annex B

Contractor HSE Evaluation Form

Company:
Address:
Phone:
Project:
Start Date: End Date:

An evaluation of the above mentioned contractor has been conducted. The following documentation has
been provided and is attached:

YES NO Please explain why information is missing in COMMENT


the comment section.
Contractor HSE Profile
Project Chemical Inventory and MSDSs
Waste Disposal Plan
Employee Training
Proof of Liability Insurance
Specialized Equipment (if required)
Injury and Illness Data – Social Insurance
Environmental Violation History
Skill / Trade Certification Records
Records of First Aid / Medical Care Provision
Emergency Response Plans
HSE Program Table of Contents
HSE Meeting Report
HSE & Housekeeping Inspection

I met with company representatives listed below to review their HSE program:

Name Title

 This company has met our minimum HSE requirements and should be permitted to bid on
projects.

 This company has not met our minimum HSE requirements and should not be permitted to bid
on projects.

 This company has not met our minimum HSE requirements, but they should be permitted to bid
on projects with these restrictions:

Evaluated By: _________________________________ Date: ______________

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