Pre QualificationQuestionnaire by YQG6f0

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									QS16 - Issued 25/05/10




                                                          4. References Taken

                                                          Ref 1


                                                          Ref 2
         Fast Track Health & Safety Sub-contractor
                     Assessment Form

      Trade :                            ……………………………….    5. Tax Details

      Contract Ref :                     ……………………………….    UTR Tax reference                                 ……………………………….

      Contract No. :                     ……………………………….    Company Registration Nr.                          ……………………………….
                                                          or
                                                          National Insurance Nr.                            ……………………………….
      Proposed order value £             ……………………………….

      1. Contractor Details                               6. Insurance Details

      Name                                                Public liability - min £2m                £       ……………………………….

      Address 1                                                                           Expires           ……………………………….

      Address 2                                           Employers liability - min £2m             £       ……………………………….

      Address 3                                                                           Expires           ……………………………….

      Address 4                                           PI liability - level of cover             £       ……………………………….

      Address 5                                                                           Expires           ……………………………….

      Address 6
                                                          7. H & S Qualification
      Post Code
                                                          3rd party H & S accreditation                              Yes / No
      Tel No:                                             (SEE NOTE AT BASE OF PAGE)

      Fax No:                                             Name of Scheme Provider :                         ……………………………….
                                                          (Only CHAS / EXOR / Safecontractor / Achilles / SSIP)
      Contact Name :
                                                          Expiry Date of 3rd party accreditation :          ……………………………….
      Email address :
                                                          Labour - H & S competance                                  Yes / No
      Mobile No:                                          card scheme in place?
                                                          (CSCS or equivalent)

                                                          Percentage of work force carded                              %
      2. Basic Health & Safety
                                                          First aid trained operatives                     ratio
      No of employees inc
      labour only s/c's ?                                 Are operatives given specific
                                                          training in the work being placed                          Yes / No
      Safety policy in place?         Yes / No

      Safety policy, Part 1, page 1                       8. Accident Statistics
                 statement date?
                       signed by?                         RIDDOR notifiable incidents
                                                          last 3 years
      Is there a sub-letting
      H&S policy in place             Yes / No            HSE actions or prosecutions
                                                          last 5 years
      Will works be sub-let           Yes / No
                                                          Further information
      What elements?

      Are these high risk work?       Yes / No            9. Systems

      Risk assessment                 Generic / Bespoke   Quality system in place?                                   Yes / No
                                                                                              Ref

                                                          Environmental Policy?                                      Yes / No
      3. H & S Advisor details                                                                Ref

      Name
                                                          10. Status after checking - Approved                       Yes / No
      Qualifications
                                                          Reviewer
      Contact No:
                                                          Date of review

                                                          Distribution                              Supply chain manager + Project CM

      Important Note :-
      Completion of this fast track form only satisfies a basic H&S checking requirement.
      The sub-contractor will, in accordance with Company policy be required to achieve a
      3rd Party H & S accreditation within a six month period from the date of any order.
      Failure to achieve such accreditation will proclude the sub-contractor from inclusion
      on all future tender opportunities and from all future orders.

								
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