Laurus Labs Limited
CONTRACTOR SELF DECLARATION FORM
Please tick the appropriate check box provided below:
General Contractor Services Electrical Contractor Services
Mechanical Contractor Services Civil Contractor Services
Specialty (specify): _____________________ others: _______________________
Name of the Contractor………………………………………………………………………
Name of the Previous Company Worked………………………………………………………
Assessment Period: From: …………………………… To: ………………………..
S.No. Description of the Check point Yes/No Remarks
1. Do you have a documented Safety Policy? (If yes please
attach the copy).
2. Is your Company's Senior Management committed to safety?
3. Do you have a documented Safety Management System? (If
yes please attach the copy).
4. Do you provide task specific training to your employees?
5. Do you provide a safety induction to your employees prior to
their commencing work on a particular site?
6. Do you or your site supervisors conduct regular tool box
meetings with your employees?
7. Do you have a nominated person who will supervise the
works on site?
8. Is this supervision full time or part time?
9. Do you carry out regular inspections and maintenance on
your plant and equipment i.e. electrical equipment, tools,
machinery etc?
10. Do you carry out risk assessments and provide safe work
method statements prior to commencing work on site?
Please provide copy of safe work method statement.
11. Have you received any fines or notices from any previous
Organization/ Safety Authority in the last 5 years? If yes
Please provide details..
12. Have you ever been prosecuted by any previous
Organization /Safety Authority in the last 5 years? If yes
please provide details.
13. Contact phone numbers previous organization worked.
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Statistics Table: (Previous Project/Assignment)
S.No. Description of Item Total Remarks
1. No. of people worked
2. Total man hours worked
3. No. of First aid injuries occurred
4. Number of Lost Time Injuries occurred
5. Total man-days lost due to injuries
6. Number of Other Non-Conformances:
Legal Non-Compliances
Property damage
Ill-Health incidents
Near-miss incidents
Vehicle incidents
Safety deviation tickets
Alcoholism incidents
Theft incidents
Total Non-Conformance
DECLARATION:
I/We hereby declare that the above-furnished information is true to the best of my knowledge.
Contractor Name & Signature with Date
Conclusion:
User Department Head: Accepted By Needs for Improvement Rejected
Review Comments:
Date: Signature of the User Dept. Head
EHS Department Head: Accepted By Needs for Improvement Rejected
Review Comments:
Date: Signature of the EHS Head
HR Department Head: Accepted By Needs for Improvement Rejected
Review Comments:
Date: Signature of the HR Head
Copy to: 1) Purchase/Legal Department, 2) User Department, 3) HR Department, 4) EHS Department
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