PERTAMINA

PHE ONWJ

CONTRACTOR HEALTH, SAFETY AND ENVIRONMENT

MANAGEMENT SYSTEM (CSMS) QUESTIONNAIRE
SECTION 1 LEDERSHIP AND TOP MANAGEMENT COMMITMENT
1. Commitment to HSE through leadership
a) How are senior managers is top management personally involved in HSE
management

b) Provide evidence of commitment at all levels of the organization by :

(I) Stating this years company targets for HSE performance :

(II) Describing how you ensure that your organization understand and is
committed to deliver your company HSE targets

c) How do you promote a positive culture forwards HSE matters?

SECTION 2 POLICY AND STRATEGIC OBJECTIVES

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2.1. HSE Policy & Documents

a) Does your company have on HSE policy document that is applied in this
region
(Yes / No) if yes, please attch.

b) Who has overall and final responsibility for HSE in your organization ?

c) How do you ensure HSE Policy compliance and communication at site?

2.2 Availability of Policy Statement to Employees

How do you communicate your companys policy to your employees including
any changes ?

STANDARDS AND DOCUMENTATION

3.1. Organizations Commitment and Comunication
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a) How management Involved in HSE Activities, objective setting and

monitoring ?

b) What provision does your company make for HSE communication and
meeting?

3.2 Competence and Training of Manager /Supervisor/Senior Site

Staff /HSE Advisor
Have the managers and supervisors at all levels that will plan, monitor, oversee
and carry out the work received formal HSE training in their responsibilities with
respect to conducting work to HSE requirements ?
(Yes/No)

3.3. Competence and General HSE Training

a) What arrangements does your company have to ensure employees have
knowledge of basic industrial HSE, and to keep this knowledge to date ?

SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES,

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STANDARDS AND DOCUMENTATION

3.4. Specialized Training
How have you identified areas of your companys operations where specialized
training is required to deal with potential hazards? Please itemize and provide
details of training given?

3.5. HSE Qualified Staff Additional Training

Does you company have HSE specialist (related to your companys services) who
can provide training for other employees ? (Yes/No)

If Yes, please attach the curriculum vitae

3.6. Assessment of Suitability of Subcontractors

Do you employ sub-contract(S) for the intended service ? (Yes/No)

If No, please go to the question 3.7.

Do you have sub-contractor (s) selection procedure in term of HSE?

b) How do you asses you sub-contractor(s) to ensure they comply with your
companys HSE policy and standards?

SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES,

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STANDARDS AND DOCUMENTATION

3.7. Standards
a) What kind of HSE regulatory or industrial standards that your company refer
to for the Intended service ?

b) who do you ensure these are met and verified ?

SECTION 4: HAZARD AND EFFECT MANAGEMENT

Does you company have procedure fo the Identification, assessment, control and
mitigation of Hazards and effects ? (Yes/No)

If Yes, please attach the index/table of content including the sub-Index

4.2.Exposures of the Workface

What systems are in place to monitor to hazards exposure of your workface e.g.
chemical of physical agents ?
4.3. Handling of Potential Hazards
How is your workface advised on potential hazards, e.g. chemical nolse,
radiation, etc,, encountered in the course of their work ?

SECTION 4: HAZARD AND EFFECT MANAGEMENT

4.4. Personnal Protective Equipment
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a) What arrangements does your company have for provision and unkeep of
protective equipment and clothing, bolth standards issue, and that required
for specialized activities ?
b) Do you provide appropriate personal protective equipment (PPE) for your
employees? (Yes/No)
Please provide a listing of the PPE for the scope of this work.
c) Do you provide training on how to use PPE ? (Yes/No)
Explain the content of the training and any follow-up
d) Do you have a program to ensure that PPE is impacted and maintained ?
4.5. Waste Management
a) What systems are place for identification, classification, minimization and
management of waste?
b) Please provide the number of accidents resulting in environmental damage in
the amount greater
than $50,000 for the last 24 months. Attach copies of any governmental
reports submitted ?
c) Do you have procedures for waste disposal? (Yes / No)
d) Do you have procedures for spill reporting ? (Yes / No)
e) Do you have procedures for spill clean up ? (Yes / No)
f) Please provide details at any of your equipment related to environmental
matters.

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SECTION 4: HAZARDS AND EFFECT AMANAGEMENT

4.6. Industrial Hygiene
a) Do you have an Industrial hygiene program ? (Yes /No)
Please describe this process, if Yes, please provide the list.
4.7. Druge and Alcohol
Do you have a drugs and alcohol policy in your organization? (Yes /No) If Yes,
please attach

SECTION 5 : PLANNING AND PROCEDURES

5.1. HSE or Operations Manuals
a) Do you have HSE procedures manuals ? (Yes / No) If Yes, please attach the list
of content
b) How do you ensure that the working practices and procedures used by your
employees on-site are
consistently in accordance with your HSE policy objectives and arrangements?
5.2. Equipment Control and Maintenance
How do you ensure that plant and equipment used within your premises, on-site,
or at other locations by your employees are correctly registered, certified with
regulatory requirement, inspected, controlled and maintained in a safe working
condition?
5.3. Transport Safety Management and Maintenance
What arrangement does your company have for vehicle incidents prevention?

5.4 Lifting Operation Procedure (if applicable)

Do you have any procedures to control the work Involved in Lifting operation?
5.5. Maintenance Schedule of Lifting Operation Equipment (If
applicable)
Do you have any Inspection, testing, maintenance and certification programs and
schedule for lifting equipment e.g. crane, forklift and rigging equipment ?

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5.6 Competency of Lifting Operation Personnel (if applicable)

Do you have system to ensure that the lifting team, e.g. lifting equipment
operators, banksmen (signalmen) and rigging personnel are competent ?

SECTION 6 : IMPLEMENTATION AND PERFORMANCE MONITORING

6.1. HSE Management and Performance Monitoring of Work Activities
a) What arrangement(s) does your company have for supervision and monitoring
of HSE
performance?

b) What arrangements does your company have for passing on any results and
findings of this supervision and monitoring to your:
(I)

Base Management

(II)

Site Employees

c) Has your company received any award for HSE performance achievement? (Yes
/No)
6.2. Statutory Notifiable Incidents/Dangerous Occurrences,
Improvement Requirement and Prohibition Notices
Has your company suffered any improvement requirement or prohibition notices
on statutory notifiable incidents/dangerous occurrences by the relevant national
body, regulatory body for HSE or other enforcing authority or been prosecuted
under any HSE legislation in the last five years?
If yes, please give the number of occurrences and its short description.
6.3. HSE Performance Records
a) Please provide statistical details of your HSE performance over the past 3
years (if Not recorded /applicable please mark N/R or N/A

Total Number

Frequency

( Incl. All contract & sub contract

personnel)

( based on OSHA)

Fatalities
Day Away From Work Cases (DAFWC) or LTls
Total Recordable Cases (e.g. Medical Treatment, Restricted Work, Transfer to Another
Job, Unconsciousness)

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b) How is health performed recorded ??

c) How is Environmental performance recorded ?

SECTION 6 : IMPLEMENTATION AND PERFORMANCE MONITORING

6.4.Incident Investigation and Reporting
a) Do you have a procedure for the investigation, reporting and follow-up of
accident, dangerous
accurances or occupational illnesass ? (Yes/No) if Yes, please attach

b)

How are the Findings following on investigation, ar a relevant incident

accruing elsewhere, communicated to your employees ?

Please attach on example of investigation reports during the last 12 months.

SECTION 7: AUDIT AND REVIEW

a) Do you have a written policy on HSE auditing ? (Yes/No)
b) How does this policy specify the standards for auditing, including schedule,
coverage and the qualifications for auditors ?
c) How is the effectiveness of auditing verified and how does management report
and follow up auditors ?

SECTION 8 : EMERGENCY RESPONSE PROCEDURE

Do you on emergency response plan ? ( Yes/No) if yes, please attach

SECTION 9: HSE MANAGEMENT ADDITIONAL FEATURES

a) Do your company hold association (s) membership ? (Yes /No)
If Yes, please provide the list
b) Are there any aspect of your HSE performance that you believe dilfferentiates
yourselves from your competitors that not described elsewhere in your response
to the Questionnaire ?
If yes, please explained

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