SERVICE PROVIDER NAME:

SERVICE PROVIDER LOCATION:

DATE OF ASSESSMENT:

NAME OF PERSON COMPLETING

FORM:
CONTENTS

About the Assessment

Company Particulars

Section 1 Financial Checks

Section 2 Quality Management System

Section 3 Environmental Management System

Section 4 Health & Safety Management System

About the Assessment

To ensure that ALPHA & GODMAN ENGINEERING SERVICES LTD retain its corporate and international Health, Safety, Environmental & Quality
(HSEQ) management system to maintain a safe working environment in all areas this contractor assessment process is designed to provide DOL with
an overview of contractors and to assist them in objectively assessing their HSEQ Management System and their approach to managing associated
risk.

A fundamental element of effective safety management is risk assessment. The use of this guide can assist the contractor in demonstrating to AGESL
that risks have been identified, analysed, and reduced to a level which is As Low As Reasonably Practicable (ALARP).

An effective management system demonstrates the following basic attributes:-

Management identifies the companys values and aspirations in Policy Documents

Procedures are developed to meet the objectives of these policies.
Competent personnel are employed to implement the procedures
Adequate training is provided
Adequate resources (personnel, time and equipment) are assigned
Plant and equipment is properly maintained.
Incidents and near misses are investigated to determine root causes so that effective corrective actions can be implemented
Systems to identify and analyse risk so that risk control measures can be identified, adequately resourced and targeted most effectively
The system is auditable and quantifiable indicators are used to measure the systems effectiveness and trends.
There is a culture of continuous improvement.

All Service Provider Must complete Sections 1 & 2, All Sections must be completed.

Once completed, the assessment is to be returned to AGESL and will be reviewed by AGESL Management.

On completion of a review of the submitted assessment and any supporting documentation AGESL will consider whether a further audit of the company
management is required to meet AGESL obligations in managing Suppliers/service providers.
 COMPANY PARTICULARS
Company Name:

Address:

Contact Person:

Telephone Number:

Fax Number:

Email Address:

Emergency Contact Person:

Emergency Telephone Number:

HSEQ Contact and Job Title:

Operating Areas(s):

Number of Employees:

Affiliations/Joint Ventures:
 SCOPE OF WORK (Mandatory)

SECTION 1 FINANCIAL CHECKS

Please enter answer here
1 Are your organisations bank details attached to facilitate a credit account?

SECTION 2 QUALITY MANAGEMENT SYSTEM

Please enter answer here
1 Is the Organisation ISO 9001 or 9002 certified? If yes, please attach the current
certificate.

2 If the answer to Section 2, question 1 is NO, does the organisation have a

documented quality system? Provide evidence

3 Is the organisation approved by an IACS approved organisation, e.g. Class

Society such as Lloyds Register, DNV, ABS, BV etc?

4 If the organisation is not ISO 9001 or 9002 certified, state if intending to apply for
quality system certification? (i.e. within 6 months, 12 months or never)

5 Can the organisation provide either test certificates or certificates of conformity?

6 Is organisation willing to permit quality audit by AGESL or nominee?

7 Number of employees:
Clerical
Production
Q.A/Q.C
SECTION 3 - ENVIRONMENTAL MANAGEMENT SYSTEM
1 Is the organisation certified to ISO 14001? If yes please attach current certificate.

2 If No, Is it the organisations intention to attain certification to ISO 14001? If so

please state time scale.

3 Explain how your company manages Environmental matters

4 Does your organisation have plans in place to prevent/minimise pollution

attributable to company activities? If Yes provide evidence.
If No, why Not?

SECTION 4 - HEALTH & SAFETY MANAGEMENT SYSTEM

Please enter answer here
1 Does the company operate a certified OHSAS 18001 system?
If yes please attach current certificate.

2 Does your organisation have a documented Health and Safety system/Policy? If

yes please provide a evidence.
If No, how does your company manage Health & Safety matters?

3 Who has overall responsibility for Health and Safety within your organisation?
Please provide company Organisational chart.

4 Does the company maintain up to date records of qualifications, experiences and

Training courses for all staff? If Yes provide sample document. If No, why Not?
 SECTION 4 - HEALTH &SAFETY MANAGEMENT SYSTEM
5 Do key personnel undergo regular medical evaluations? If Yes, please provide
evidence. If No, why Not?

6 Is there a formal induction policy for new recruits? If Yes provide sample
document. If No, why Not?

Is there a procedure in place which defines the prompt reporting and investigation
7 of all incidents/accident/near miss? Provide evidence

8 Provide details of the last 3 years incident and accident statistics which must
include details of Environmental incidents.

9 What arrangements do you have collecting and analysing information regarding

lost time incidents?
If available please give details of your analysis for the past 2 years.
If No why Not?

10 Please provide examples of appropriate safe system of work in place (safety

procedures, safety manuals, Risk Assessment, Method Statement, Job safety
Analysis).
11 How does your organisation ensure that plant, equipment, machinery, vehicles,
vessels (owned or hired) for use are maintained and kept in a safe condition?
Provide evidence of maintenance record.

12 Please provide details of hazardous substance to be used on this work that are
classified hazardous to health.

13 Does your organisation sub-contract work to other companies? If yes how is this
managed?

SECTION 4 - HEALTH & SAFETY MANAGEMENT SYSTEM

14 Does your organisation have a detailed contingency plan that covers all
 emergency scenarios? If yes please provide evidence

15 Is organisation willing to permit a HSE audit by AGESL or nominee?

Date of Issue Duration of trading/use Grade Approved by Date to be reviewed

Criteria for approval/comments

On-going Performance
Date Comments continue overleaf

If the aforementioned information does not give a representative HSEQ assurance profile of your operation, then please
give a more appropriate outline on a separate sheet on your company headed paper, together with your signature,
position within the company and the date.

Please complete the following:

Signed: .. Date:

Position:

Thank you for taking the time to complete this questionnaire.