NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

PM-NCR-03.08-F.03
Revised Form: CSHP Form 1A-2023:
Revised Form: CSHP Form 1A-2023 Page 2 of 3
Date of Revision: 30 April 2023
 Department of labor and Employment
APPLICATION FORM
REGIONAL OFFICE NO. ______
FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

OSH Personnel assigned to the project

Name Date of training Designated First Aider:

Designated Safety Officers: Name Date of ID Validity

(Please attach photocopy of Certificate of Completion on the Basic OSH Course for Construction Site Safety training

Officers issued by DOLE-BWC accredited Safety Training Organizations or recognized instit ution) Please attach a photocopy of the Certificate of First-Aid Training and valid First Aid ID from Phil Red
Cross, DOH, Bureau of Fire and DOLE- Accredited TVIs with 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. 1.

2. 2.

3. 3.

4. 4.

5. 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:

Other Qualifications:

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:

Signature Over Printed Name of the Owner/Contractor Position Date

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