NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP
Revised Form: CSHP Form 1A-2023:
Date of Revision: 30 April 2023 Page 1 of 3
APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ________ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Legal Bases: Type of Construction Project:
1. Presidential Decree No. 442, as renumbered _____DPWH project
2. Republic Act No. 11058 _____Other Public/private construction project
3. Department Order No. 198, Series of 2018
(LGUs, other gov’t offices, private entities)
_____ Residential project engaging the services of
a construction firm
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR/SUBCONTRACTOR/BUILDING OWNER in applying for a Construction Safety and Health
Program intended for a specific construction project.
Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with
complete requirements and attachments will be processed.
A. Company Profile/License/Registration of Main/General Contractor
Complete Name of the Company/Main/ Complete Office Address:
General Contractor/Project Owner
Tel. No: __________________________________________________
Fax No. ___________________________________________________
Name of Project Manager/Owner/ Tel. No: ___________________________________________________
Contact Person: Email: _____________________________________________________
Contractor’s PCAB/JV License No: Number of workers:
________________________________
Male: _____ Female: _____ Total employment: _____
Date of Validity:___________________
Engaged Subcontractors’ Profile
Name of Sub-contractors Scope of Work and No. of Workers PCAB Date of Date of DOLE
(If any) Project Cost License Validity Registration
1.
2.
3.
4.
5.
6.
7.
(Use separate sheet, if necessary)
APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ________ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
B. Project Profile/Description
Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or other documents indicating
name and details of the project)
Complete Project Address/Location:
Name of Project Owner: Tel. No: _____________
Fax No: _____________
Email : _____________
Project Classification: Estimated No. of Workers to Date of Estimated Start/Execution of the
be deployed in the project: project:
___________________ ________/________/_________
Month Day Year
(Workforce of the project to
Total Project include workers of the sub- Duration of the project (Pls. state the number
Cost:__________________ contractor/s) of calendar days)
___________________________
Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary)
Revised Form: CSHP Form 1A-2023 Page 2 of 3
Date of Revision: 30 April 2023
APPLICATION FORM
Department of labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ______ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
OSH Personnel assigned to the project
Designated Safety Officers: Designated First Aider:
Name Date of Name Date of ID
training training Validity
(Please attach photocopy of Certificate of Completion on the Basic Please attach a photocopy of the Certificate of First-Aid
OSH Course for Construction Site Safety Officers issued by Training and valid First Aid ID from Phil Red Cross, DOH,
DOLE-BWC accredited Safety Training Organizations or Bureau of Fire and DOLE- Accredited TVIs with TESDA
recognized institution) registered EMS and other DOLE-Accredited first aid
training provider
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of required BOSH Training
OH Nurse
OH Physician
Dentist
(If Heavy Equipment will be used in the Project)
List of heavy equipment to be used in the Project: Name of Heavy Equipment Operator/s:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
(Please attach additional sheet, if necessary.) (Attach photocopy of skills certification from TESDA.)
Profile of the person who prepared the CSH Program for the abovementioned Project
Educational Background:
Work Experience in OSH:
___________________________
Signature over printed name Other Qualifications:
I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULNESS OF THE ABOVEMENTIONED INFORMATION. THE COMPANY HEREBY
COMMITS TO STRICTLY IMPLEMENT THE ATTACHED CONSTRUCTION SAFETY AND HEALTH PROGRAM DESIGNED FOR THE
ABOVEMENTIONED PROJECT.
Submitted By:
Signature Over Printed Name of the Position Date
Owner/Contractor
Assigned Evaluator
I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON
THE DOLE PRESCRIBED CHECKLIST.
Evaluated By:
Signature Over Printed Name Position Date
