PERSYARATAN HSE QUESTIONNAIRES Peserta Lelang wajib melengkapi dan melampirkan dokumen pendukung untuk HSE QUESTIONNAIRE ini. Peserta Lelany harus mengembalikan dokumen HSE QUESTIONNAIRES tersebut paling lambat hari Senin, tanggal 24 Juni 2010. Perusahaan berhak melakukan Klarifikasi atas setiap dokumen yang disampaikan oleh Peserta Lelang. Hanya Peserta Lelang yang telah memenuhi batas nilai minimum 56, yang akan diundang untuk tahap pelelangan ini.CARIGALL HSE QUESTIONNAIRES Company Type of Work = Section 1: Leadership and Commitment 4.41 Commitment to HSE through leadership (a) Are senior managers personally involved in HSE management? Attached: HSE Policy, Field Management Visit Report, Minutes Of Meeting (MOM) HSE, HSE Objective, Target, and Program 1B) 1s there evidence of commitment at all levels of the organization? Attached: HSE Management MOM, and Participant List Te) Is there a positive culture towards HSE matters? 2.1 HSE policy documents Ta) Does your company have an HSE policy document? Cl¥es CrNo {f the answer is YES please attach 2 copy. Attached: Copy of HSE Policy Ty Who has overall and final responsibilty for HSE in your organization? Attached: Organization Chart with personnel highlighted, Curriculum Vitae HSE personnel. {é) Who is the most senior person in the organization responsible for this policy being cantied out at the premises and on site where his employees are working? Provide name, title and experienc ‘Attached: Organization Charts including HSE Funetions and Responsibilties, 2.2 Availability of Policy Statement to Employees Ta) Temize the methods by which you have drawn your policy statement fo the attention of all ‘employees. ‘Attached: communication method such as bulletin board, and slip “receipts it is read and or understood” {by What are your arrangements for advising employees of changes in policy? Attached: emails, memo, receipt of statement 3.1 Organization - Commitment and Communication Ta) How is management involved in HSE activities, objective-setting and monitoring? Altached: HSE Management Review Report, Management HSE MOM, etc 10f7{b) Does your company have an HSE organization? Q Yes — C1No’ If YES, please attach and describe the roles and responsibilty, Attached! Organization Chart (e) How is your company structured to manage and communicate HSE effectively? Attached: Documentation for HSE Communication (@) What provision does your company make for HSE communication meetings? Attached: MOM HSE 3.2 Staff HSE training Have the managers and supervisors at all levels who will plan, monitor, oversee and carty out the work received formal HSE training in their responsibilities with respect to conducting work to HSE requirements? O Yes C1 No If YES please give details. Where the training is given in-house, please describe the content and duration of courses. Attached: HSE Training procedure, Training Certificate, Training Need Analysis 3.3 Employee orientation and training program (a) What arrangements does your company have to ensure new employees have knowledge of basic industrial HSE, and to keep this knowledge up to date? ‘Attached: Induction Program or Report, Induction bookiet {b) Whai arrangements does your company have to ensure new employees also have knowledge of your HSE policies and practices? Attached: Training Certificate and induction Program {é) What arrangements does your company have fo 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? Attached: Risk Analysis, HSE Induction and Training Certificate or Attendance List (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.) ‘Attached: Training Certificate and Induction Program : 3.4 _ Specialized training (a) Have you Wentified areas of your company’s operations where specialized training is required to deal with potential dangers? (If YES please itemize and provide details of training given.) Attached: Hezard List and Training Program for each — First Aid, Fire Fighting, Evacuation Drill (1) ithe specialized work involves radioactive, asbestos removal, chemical or other occupational health hazards, how are the hazards identified, assessed and controlled? Attached: Procedures and Implementation Records (samples) , HSE Certificates 3.8 _ HSE qualified staff - additional training ‘Does your company empioy any staffs who possess HSE qualifications that aim fo provide training in more than the basic requirements? DYes CINo ‘What type of safety qualification does your staff have? Please describe. Attached: Certificates, Training Program and Attendance List 20f73.6 Sub-Contractor a) How do you assess (i) HSE competence? ‘Attached: Sub-contractor HSE Management procedure, Report HSE Evaluation for subcontractors (ii) HSE record of the subcontractors and companies with whom you place contracts? Attached: HSE records of subcontractors 'B) Where do you spell out the standards you require to be met? Attached: Copy Contract HSE Statement and witness ©) How do you ensure these are met and verified? Attached: Copy Contract or memo or MOM ‘d) Please provide the names of major sub-contractors, if known at this fime, Altached: names of major subcontractors 3.7 Standards ’@) Do you have HSE standards? Attached: List HSE standards and regulations that applicable, HSE Standard and regulation documentation by How do you ensure these are mel and verified? Attached: audit certication Ts there an overall structure for producing, updating and disseminating standards? Attached: email, receipts Seaview & fs oe § nee aE: 44 Hazards and effects assessment Vihat techniques are used within your company Tor the Wentiication, assessment, control and recovery of hazards and effects? Attached: Samples Risk Anelysis, Hazard and Effect Management Procedures, JSA 4.2 _ Exposure of the workforce Do you ave in place any systems to monitor the exposure of your workforce to chemical or physical agents? Attached: HSE Inspection records, environmental monitoring records, MCU records. 4.3 _ Handling of chemicals Tiow 1s your workforce advised on the properties of chemicals encountered in the course of their work? Attached: memo, MOM, toolbox, training, MSDS ‘44 _ Personal Protective Equipment “ay What arrangements does your company have for provision and upkeep of protective clothing, both standard issue, and that required for specialized activities? Attached: PPE Procedures, PPE Stock Records and Maintenance ’) Do you provide proper and appropriate Personnel Protective Equipment (PPE) for your staff? Provide list of PPE for this scope of work. Attached: Employees Receipt 3of7@) Do you provide training on the use of PPE? Describe the training content and follow-up actions. Attached: Attendant List, training material @) Do you have a program fo ensure how PPE is used and maintained? Please describe. Attached: Observation Cards /Inspection Report 45 Waste management ‘a)_ Does your company have in place systems for identification, Classification and management of waste? Attached: Ref Pages of Manual or Procedures By Is the system in accordance with prevailing regulation? <) Please provide the number of accidents resulting in environmental damage in the emount greater than USD 50,000 for the last 24 months. Attached copies of any governmental reports. submitted Attached: Copy of Report sent to Government. @ Do you have procedures for waste disposal? (Yes T1No Attached: 4.50 %) Is the system in accordance with prevailing regulation? 1) Do you havé procedures for spill reporting? G Yes CNo Attached: Procedures @) Do you ave procedures for spit clean-up? Yes CNo AY Please provide details of any of your equipment related fo environmental matters. J Who & the person in charge of Coordinating environment matters and what is his/her experience? Attached: Curriculum Vitae ‘4.6 Industrial Hygiene @) Do you have an industrial hygiene programe? CI Yes No If so, what does it include? ‘Attached: procedures or program IH De you Fave @ risk assessment, or similar type method, for identifying work place hazards? Pigase describe this process. ‘Attached: Risk Assessment, inspection records ‘) I you Introduce hazardous materials/substances into the work site, describe the process you will use to document and control these. ‘Attached: MSDS. 47 _ Drug and Alcohol ‘Does your company have a drug and alcohol policy? If 80, does it include pre-employment test and random test? Attached: Drug & Alcoho! Policy, MCU records, drug & alcohol test. Settion 5: Hanning and Peonadiees, 64 HSE or operations manuals a Do you have @ 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 such as scaffolding, lifting equipment, chemical handling, excavation, etc.? Gyes No ae 40f7Trthe anewer is VES please aiach a copy of supporting documentation Attached: HSE manual 3) 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? Attached: procedures 5.2 Equipment control and maintenance Flow do you ensure that plant and equipment used within your premises, on-site, or at other locations by your employees are correctly registered, controied and maintained in a safe working condition? Attached: equipment inspection records 6.3 __ Road Safety Management What arrangements does your company have for combating road and vehicle incidents? Attached: procedures, vehicie inspection checklist/records ‘Seaton Sih f * : 6.1 Management and performance monitoring of work activities a) What arrangements does your company have for supervision and monitoring of performance? ‘Attached: MOM, HSE report, inspection records By What types of performance criteria are used in your company, give examples. Attached: HSE report <) What arrangements does your company have for passing on any results and findings of this supervision and monitoring to your: (V), base management Gi) site employees? Attached: MOM, toolbox, memo, emails @ Has your company received any award for HSE performance achievement? Dyes No IFYES, please submit copies. Attached: copy of HSE awards 6.2 Safety Meoting Program "a) Do you organize in-house safely meetings? Yes CINo Please describe the frequency. attendance and topics. Attached: MOM, attendance list b) Do you organize campaigns to simulate safe working practices? Yes ~C1No If 80, please give details. Attached: HSE program, including poster, notice board, toolbox, etc. 6.3 _ Statutory notifiable Incidents dangerous occurrences “ay Has your company suffered any statutory notifiable incidents in the last five years (safety, ‘occupational health and environmental)? C1 Yes C1 No (IF YES, provide detaiis including dates, most frequent types, causes and follow-up preventative ‘measures taken.) ‘By Has your company suffered any improvement requirement or prohibition ntioes by the relevant national body, regulatory body for HSE or other enforcing authority or been prosecuted under Sof7‘any HSE legislation in the last five years? Yes GINO) (ityour answer is YES please give details.) = 6.4 HSE Performance Records 3) Have you maintained records of your incidents and HSE performance for the last five years? Yes (No (IF YES, please give following details for each year, number of Non Lost Time Injuries, number of Lost Time Injuries, number and type of injuries, total hours worked by workforce for each corresponding year, Frequency Rates, your company definition of a Lost Time incident. Also attached your Company's definition of the above terms. Attached: HSE performance statistic records for the last five years b) _ Hows health performance recorded? )__ Howis environmental performance recorded? ‘@)__ How offen is HSE performance reviewed? By whom? 65 _ Incident investigation and reporting ‘2) Do you have a procedure for the investigation, reporting and follow-up of accidents, dangerous ‘occurrences or occupational ilinesses? C1 Yes C1No IFYES, please attach Attached: procedures ‘By Who Conducts incident investigations? %) How are the findings following an investigation, or a relevant incident occurring elsewhere, ‘communicated to your employees? Altached: HSE alerts @) Are néar misses reported? Grves CNo @) Please provide copies of investigation reports for the last 12 months, Attached: incident investigation report. ‘Do you have a written policy on HSE auditing? Attached: policy, procedures b) Tow does this policy specify the standards for auditing (Including unsafe act auditing)? °) ‘Does your company HSE Plans include schedules for auditing and what range of auditing is covered? Attached: audit program @) Please provide a list of procedures. Describe how emergency preparedness is maintained and the ‘command structure in case of emergency. Attached: Emergency Response Plan, emergency drill records. Taw is the effectivenass of auditing verified and how does management report and follow up audits? Got7Section 9: HSE Management ~ Additional Features 2) Dees your company hold membership of any industry, rade or HSE organization? Attached: copy of company membership Sy Does your company have any ether HSE features or arrangements not described elsewhere in your response to the questionnaire? Contractor Representative NameiDate Tof7