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					〔様式1〕                                                                                                                                                                                          Date Filled Out:
  Survey Sheet for Business Partner (Regarding Environmental Control) [A]                                                                                               Company name
[Instructions on filling out the form]                                                                                                                                   Division name
①Read the following questions and select a self-evaluation score from the alternatives, and describe specific implementation status in the
space for Evaluation Comments.                                                                                                                                               Person
                                                                                                                                                                                         (Position)               (Name)              
Alternatives: ○・・・Yes △・・・Partially implemented, or to be implemented within a year ×・・・No Not Applicable: Do not apply                                                  responsible for
②If you have acquired ISO 14001: 2004 or other environmental management system, please be sure to answer Questions No. 1 and Nos. 8-
14. If you have not acquired any system, or are planning to acquire, be sure to answer all the questions.                                                               Contact Division
③If you are a trading company, it is requested that this form be filled out by the manufacturer.
④The columns for Company name, Division name, and Person responsible for the contents should be filled out by Manufacturing Division.
                                                                                                                                                                        Contact Person
⑤The columns for Contact Division and Contact Person should be filled out by the Division in charge of delivering products to Ibiden’s                                  Contact Number (TEL)                      (FAX)
Purchasing Division.
⑥Ibiden’s person in charge may conduct an audit of your company based on the contents of the form submitted.                                                             E-mail address


No.                                                 Questions                                                   Scores Self-Evaluation                                      Evaluation Comment                      (*) Space to be filled (out) by Ibiden
    Have you acquired ISO 14001:2004 or any other environmental management system (Eco-                                                      (Name of Standard)         (Certification Body)
  1 stage/Eco-Action 21/EMAS/KES, etc.)? (If the answer is “YES”, then it is not necessary to                     30
                                                                                                                                             (Date of acquisition or scheduled date of acquisition)
    answer the following questions.)
  2 Has an Environment Policy been formed by CEO, and is it regularly reviewed?                                    5

      Is there an organization in charge of environmental control, and are the responsibility and
  3                                                                                                                5
      authority of each department made clear?
    Is there any system to watch out for and comply with the latest environment-related
  4                                                                                                                5
    regulations?
    Do you recognize your own activities that may affect the environment, and take any measures
  5 against such activities making a great impact on the environment so as to reduce their                         5
    environmental loads?
    Do you have a system to monitor the progress in the environmental load reduction activities
  6                                                                                                                5
    mentioned in No. 5 as well as to evaluate the results?

  7 Do you conduct an internal audit on your environmental conservation efforts?                                   5

    Do you conduct periodical training for a procedure to cope with process abnormalities and
  8 emergencies including acts of God, and do you revise such procedure according to the results                  10
    of training?
    Do you comply with all the laws and regulations concerning pollution regarding air and water
  9 qualities, noises, vibrations, wastes, etc. as well as your own emission standards, and do you                10
    immediately rectify any defects?

 10 Do you set plans • targets in performing activities regarding 3Rs (Reduce, Reuse, Recycle)?                   10

 11 Do you set plans • targets in performing activities regarding prevention of global warming?                   10

 12 Do you actively publicize your efforts for environmental conservation?                                        10

      Do you conduct training of all your employees for pollution prevention or environmental
 13                                                                                                               10
      conservation?
    Do you have rules for Green Procurement which clarify substances prohibited from
 14                                                                                                               10
    procurement and reference values therefor?
                                                                                 Total                           100            0
                                                                                                                                                                         Date Filled Out:
  Survey Sheet for Business Partner (Regarding Product) [B]                                                                                             Company name
[Instructions on filling out the form]
①Read the following questions and select a self-evaluation score from the alternatives, and describe specific implementation status in the space for
                                                                                                                                                         Division name
Evaluation Comments.                                                                                                                                   Person responsible (Position)        (Name)
Alternatives: ○・・・Yes △・・・Partially implemented, or to be implemented within a year ×・・・Not Applicable: Do not apply                                    for the contents:
                                                                                                                                                        Contact Division
②Please be sure to answer all the questions.
③If you are a trading company, it is requested that this form be filled out by the manufacturer.                                                        Contact Person
④The columns for Company name, Division name, and Person responsible for the contents should be filled by Manufacturing Division.
⑤The columns for Contact Division and Contact Person should be filled by the Division in charge of delivering products to Ibiden’s Purchasing           Contact Number (TEL)                (FAX)
Division.
⑥Ibiden’s person in charge may conduct an audit of your company based on the contents of the form submitted.                                            E-mail address


No.                                                  Questions                                                    Scores Self-Evaluation                  Evaluation Comment                    (*) space to be filled by Ibiden
      Do you have your own policy concerning control of chemical substances contained in
  1                                                                                                                  4
      products, and are all the employees familiar with the policy?
      Are the standards for controlling chemical substances contained in products and the ranges to
  2   which the control standards apply                                                                              4
      (Divisions/Departments•Business•activities•process・products, etc.) clear?
      Do you set targets regarding controlling of chemical substances that are contained in
      products, and do you monitor the progress of the activities? Do your management
  3                                                                                                                  4
      executives, etc. review the actual results vis-a-vis the targets and reflect the results of the
      review in the targets of the subsequent year?
      Is there an organization for controlling chemical substances contained in products, and are
  4                                                                                                                  4
      the responsibilities and authorities made clear?
      Do you obtain information about chemical substances contained in purchased materials when
  5   designing and developing your products, and check whether the chemical substances                              8
      contained in the developing product comply with your control standards for chemical
      In selecting suppliers, do you check their implementation status regarding control of chemical
  6                                                                                                                  8
      substances contained in products of the supplier?
      When receiving purchased materials, do you periodically check them whether they meet your
  7                                                                                                                  8
      control standards?
      When handling, in your own process or at your subcontractor, substances prohibited from
  8   being contained or substances under use control by Ibiden, do you take measures to prevent                     8
      such substances from being misused or mixed into the products to be delivered to Ibiden in
      When a part or all of the production is outsourced to external contractors, do you properly
  9                                                                                                                  8
      check the status of control by the contractors of chemical substances contained in products?
      Do you include items to be checked regarding chemical substances contained in products in
 10   the checking list for shipment, and confirm that all the items to be checked are performed                     8
      before the products are shipped?
 11 Do you ensure traceability of products?                                                                          8
    Do you have a rule for changes in chemical substances to be contained in products, as well as
 12 a system to ensure provision of information to the customer regarding such changes before                        8
    actually implementing such change?
    Do you have rules regarding measures to be taken for nonconforming products (emergency
 13                                                                                                                  8
    measures, investigation of the cause, recurrence prevention, notification to the customers,
    Do you conduct education and training of all the employees regarding the control of chemical
 14                                                                                                                  4
    substances contained in products?
    Have you documented rules regarding chemical substances contained in products? Or have
 15 you established a system to store data on them and to properly provide information on                            4
    chemical substances contained in products upon request from customers, etc?
    Do you monitor the operation of the control of chemical substances contained in products by
 16                                                                                                                  4
    an internal audit or the like, and do you rectify any deficiencies found as a result of
                                                                                  Total                            100            0

				
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