Direct Selection No.

166/02/SR/VI/2015
Provision of Integrated Engineering Services

ENVELOPE I APPENDICES

APPENDIX B.4

CONTRACTOR HSE QUESTIONNAIRES

Attachment 2, Forms of Submittal Page 1 of 8

Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

HSE QUESTIONNAIRE
FORM

Date : _____________________________________________

Name of Contractor : _____________________________________________

Direct Selection No. : _____________________________________________

Supplier of Goods/Services : _____________________________________________

Subject : Contractor HSE Questionnaires

CUE KALIMANTAN Pte Ltd desires to continually improve their HSE performance. The
Company recognizes that vendors and suppliers contribute a large amount to our overall
HSE efforts and performance. We therefore wish to select organizations that have a
common goal and similar approach to our business principles. Only those contractors who
demonstrate management leadership and compatible systems, resulting in good safety and
health performance shall be placed on our approved vendors/service providers list. We
therefore request that you complete this HSE screening form and return it as instructed.
Those organizations successfully pass this initial screening process will be included on
COMPANY approved vendor/service provider list.
COMPANY expects that the applicant (Vendor/Service Provider) to:
Have a documented health and safety program (HSE Management System) that
meets the requirements of the goods or services that you are offering at this
screening stage.
Have a program for implementing the requirements of health and safety program
(HSE Management System)
Have a commitment to screen and apply these standards to any sub-contractor that
vendor/supplier of services may use.
COMPANY reserves the right to inspect and interview any of your personnel with the
purpose of verifying the correctness of your response.
Any falsification of facts will result in rejection / disqualification of the Vendor/Service
Provider from the approved Vendor/Service Supplier List.
Following completion and return of this documentation the submission will be evaluated.
However, marking of the submission will not occur until the data has been verified by a
COMPANY representative, following which the overall screening will be objectively marked.
The passing mark required for registration as an approved Vendor/Supplier of Services is 2/3
of the maximum score.
Successful Vendors/Supplier of Services will be given a certificate of approval with a validity
period of 2 years.

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 Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

HSE INFORMATION REQUESTED

1. ORGANISATION AND LEADERSHIP
1.1 Commitment to HSE through leadership
a. How are senior managers personally involved in HSE management?

b. Provide an example of documented evidence of commitment at all levels of the organisation as

an attachment to this questionnaire

c. How is a positive culture towards HSE matters promoted?

1.2 HSE policy documents

a. Does your COMPANY have a HSE policy document?
If the answer is YES please attach a copy

b. Who has overall and final responsibility for HSE in your organisation?

c. Who is the most senior person in the organisation responsible for this policy being carried out on
site where his employees are working? Provide name, title and experience.

d. Do you have an HSE organization?

If yes, please provide an organization chart and a description of responsibilities.

1.3 Availability of policy statements to employees

a. Itemise the methods by which you have drawn your policy statement to the attention of all your
employees?

b. What are your arrangements for advising employees of changes in the policy?

2. RISK ASSESSMENT
What techniques are used within your COMPANY for the identification, assessment, control and
recovery of risks, hazards and effects?

3. IMPROVEMENT PROGRAMMES AND WORK PLANS

How is management involved in improvement programs, objective setting and work plans?

3.1 Improvement requirement and prohibition notices

Has your COMPANY suffered any improvement requirement or prohibition notices 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 your answer is YES please give details.)

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 Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

3.2 Standards
a. Where do you spell out the standards you require to be met?

b. How do you ensure these are met and verified?

c. Is there an overall structure for producing, updating and disseminating standards?

4. TRAINING AWARENESS AND COMPETENCE

4.1 HSE training
a. What arrangements does your COMPANY have to ensure employees have knowledge of basic
industrial HSE, and to keep this knowledge up to date?

b. What arrangements does your COMPANY have to ensure new employees and contractors also
have knowledge of your HSE policies and practices?

c. What arrangements does your COMPANY have to ensure new employees have been instructed
and have received information on any specific hazards arising out of the nature of the activities?
What training do you provide to ensure that all employees are aware of COMPANY
requirements?

d. What arrangements does your COMPANY have to ensure existing staff HSE knowledge is up to
date?
(If training is provided in-house please give details of content).

4.2 Specialised training

a. Have you identified areas of your COMPANYs operations where specialised training is required
to deal with potential hazards?
(If YES please itemise and provide details of training given.)

b. If the specialised work involves hazardous materials such as radioactive, asbestos, chemical or
other occupational health hazard, has the hazard been properly identified, assessed and
controlled?

4.3 Competence and Training of managers/ supervisors/ senior site staff /HSE advisers
Have the managers and supervisors at all levels who will plan, monitor, oversee and carry out the
work received formal HSE training in their responsibilities with respect to conducting work to HSE
requirements? If YES please give details. Where the training is given in-house please describe the
content and duration of courses.

4.4 HSE qualified staff - additional training

a. Does your COMPANY employ any staff that possesses HSE qualifications that aim to provide
training in more than the basic requirements?

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 Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

3.2 Standards
b. What form of Occupational health, safety and/or environmental qualification does your
specialised HSE staff have?

5 OPERATIONAL CONTROLS
5.1 HSE and operations manuals
a. Do you have a COMPANY HSE manual (or Operations Manual with relevant sections on HSE)
which describes in detail your COMPANY approved HSE working practices relating to your work
activities?
If the answer is YES please attach a copy of supporting documentation

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

a. How do you ensure that plant and equipment used within your premises, on-site, or at other
locations are correctly registered, controlled and maintained in a safe working condition?

b. Does your company ensure that all jobs and equipment necessary for the work are used safely,
are in good condition and meet with local laws, rules and regulations?

5.3 Assessment of suitability of Contractor or other companies

a. How do you assess:
(i) HSE competence
(ii) HSE record of the subcontractors and companies with whom you place contracts?

b. Where do you spell out the standards you require to be met?

c. How do you ensure these are met and verified?

5.4 Exposure of the workforce

Do you have in place any systems to monitor the exposure of your workforce to chemical or physical
agents?

5.5 Handling of chemicals

How is your work force advised on potential hazards of substances hazardous to health (chemicals,
noise, and radiation)?

5.6 Personal Protective Equipment

What arrangements does your COMPANY have for provision and upkeep of protective clothing, both
standard issue and that required for specialised activities?

5.7 Waste management

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 Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

5 OPERATIONAL CONTROLS
Does your COMPANY have in place systems for identification, classification and management of
waste, including grey water and raw sewage?

6. EMERGENCY PREPAREDNESS
a. Provide a description of your COMPANY emergency procedure.

b. Please provide examples of a recent Emergency Response Plan and an Oil Spill Contingency
Plan

7. DOCUMENTS AND RECORDS

a. Have you maintained records of your incidents and HSE performance for the last five years?

b. How is health performance recorded?

c. How is environmental performance recorded?

d. What is your COMPANY's definition of a Lost Time Injury?

8. COMMUNICATIONS
a. How is your COMPANY structured to manage and communicate HSE effectively?

b. What provision does your COMPANY make for HSE communication meetings?

8.1 Memberships of Associations

Does your COMPANY hold membership of any industry, trade or HSE organisation?

8.2 Additional features of your HSE management

Does your COMPANY have any other HSE features or arrangements not described elsewhere in
your response to the questionnaire?
9. MONITORING, REVIEW, AUDIT AND REPORTING
a. What arrangements does your COMPANY have for supervision and monitoring of performance?

b. What type of performance criteria are used in your COMPANY; give examples

c. What arrangements does your COMPANY have for passing on any results and findings of this
supervision and monitoring to your:
- BU/SU Heads
- Site employees?

9.1 HSE performance reporting

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 Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

6. EMERGENCY PREPAREDNESS
How often is HSE performance reviewed? By whom?

9.2 HSE performance achievement awards

Has your COMPANY received any award for HSE performance achievement?

9.3 Incident investigation and reporting

a. Who conducts incident investigations?

b. How are the findings following an investigation, or a relevant incident occurring elsewhere,
communicated to your employees?

c. Are near misses reported?

9.4 Audit
a. Do you have a written policy on HSE auditing and how does this policy specify the standards for
auditing (including unsafe act auditing)?

b. Do your COMPANY HSE Plans include schedules for auditing and what range of auditing is
covered?

c. How the effectiveness of auditing is verified and how does management report and follow up
audits?

10 COMPLIANCE
10.1 Statutory notifiable incidents/dangerous occurrences
Has your COMPANY suffered any statutory notifiable incidents in the last five years (safety,
occupational health and environmental)? (Answers with details including dates, most frequent types,
causes and follow-up preventative measures taken.)

10.2 Quality Management System

a. Does your company operate a QMS? If YES, please state QMS model e.g. ISO 9000

b. How long has your QMS been in operation? Years

c. Is your QMS certified? If YES, by which Certification Body? (provide certificate)

d. Is there a current internal audit programme?

e. Are Quality Plans prepared for major contracts/equipment supply?

f. Please provide a copy of the contents index of the Quality Manual and a copy of a recent
Internal Audit Report

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 Direct Selection No. 166/02/SR/VI/2015
Provision of Integrated Engineering Services

9.3 Incident investigation and reporting

Please provide the following supporting documents, where appropriate, for this section:

g. Index of Environmental Manual and copy of recent Internal Audit Report

h. Index of HSE Manual and copy of recent Internal Audit Report
i. Index of Quality Manual and copy of recent Internal Audit Report
j. Copy of EMS, SMS and QMS certificates (as applicable)

Bidder (Company Name): ___________________________

Signature:

Name: ______________________________

Title: ______________________________

Date: _______________________________

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