Subcontractor Pre-Qualification Questionnaire - Site Safe

Subcontractor Pre-Qualification Questionnaire
1. Health and Safety Overview
1.1 What level of health and safety accreditation does
your company have?
Provide a copy of any certification.
1.2 Please provide a copy of your most recent ACC
invoice, this invoice should show your company’s
experience rating.
If your company is an Accredited Employer please
provide the following:
number of medical treatments (MTI’s) and lost time
injury's (LTI’s) per 100,000 hours for the last 5 years
2. Health and Safety Management System
2.1 A Site Specific Safety Plan (SSSP) is the minimum
required for any work you will do.
Provide an example of a recent SSSP and a contact
person in your organisation.
2.2 How do you communicate health and safety issues
to your employees?
Provide evidence and frequency.
2.3 Do you investigate all accidents and incidents?
Provide copies of completed investigations for near
miss, first aid and serious harm accidents and
numbers of each for the last year
2.4 How do you manage the safety of any
Subcontractors you may engage?
Provide evidence.
2.5 Are you and your employees trained to at least the
minimum legal requirements for the work you are
carrying out, as specified in the relevant legislation,
codes, regulations or standards, or are working
toward?
Provide your employees training and experience.
2.6 How do you identify, report and control hazards in
the workplace?
Provide an example
Subcontractor Pre-qualification Questionnaire V3 November 11

Subcontractor Pre-Qualification Questionnaire
2.7 What site inspections do you carry out for your work?
Provide a completed example.
2.8 How do you plan for significantly hazardous works?
Provide a copy of Task Analysis, Job Safety
Environmental Analysis, methodologies, notifiable
works notifications
3. Health and Safety Performance and Monitoring
3.1 What health monitoring do you carry out for your
employees?
3.2 Have you been investigated by the Department of
Labour?
If yes provide details
Result = % score from Excel spreadsheet
Drugs and alcohol is not tolerated in the Construction Industry. By signing this you accept the
zero tolerance to the drug and alcohol policy on all rebuild projects you may work on.
Contractor Details
Business Name:
Address:
Type of Business:
Postal Address:
Contact Person:
Position in Organisation:
Contact Details: Telephone: E-mail:
Mobile:
Fax:
Subcontractor Pre-qualification Questionnaire V3 November 11

Subcontractor Pre-Qualification Questionnaire
The following outlines the suitable evidence required for each of the above questions:
1.1 Accreditation can include the following:
ACC Workplace Safety Discount (WSD)
ACC Workplace Safety Management Programme (WSMP)
ACC Partnership Programme (ACC PP)
Site Safe Charter Accreditation
AS NZ 4801
ISO 9001
1.2 Your ACC invoice will include details of your Experience Rating. Copies of your ACC
invoice are available by phoning ACC on 0800 101 996
2.1 Copy of your latest Site Specific Safety Plan (SSSP) you have submitted.
2.2 Copies of health and safety committee meetings, toolbox talk minutes
2.3 Copy of accident register and or investigation forms
2.4 Copy of SSSP’s from Subcontractors or Task Analysis (TA)
2.5 Copy of training register
2.6 Copy of hazard register
2.7 Recent completed site inspection
2.8 Copy of recently completed TA’s, JSEA’s, methodologies, notifiable works notifications to
Department of Labour
3.1 Details of health monitoring you do and does this include testing for known hazards within
your work environment i.e.: hearing, lung function, pre-employment, drugs and alcohol
3.2 Details of any investigations and results of investigations by the Department of Labour
Subcontractor Pre-qualification Questionnaire V3 November 11