DPWHROXIII QAHD | DIGITAL MANAGEMENT SYSTEM

Contract ID No.:

Project Name:

Location:

A. Company Profile/License/Registration of Main/General Contractor :

Complete Name of the Company/Main/General Contractor/Project Owner:

Contructor Identification

Complete Address of the Company:

Tel. NO.:

Fax NO.:

Name of Project Manager/Owner/Contact Person:

Tel. NO.:

Mobile. NO.:

Email:

Contractor’s PCAB/JV License No:

PCAB Classification:

Date of Validity:

Number of Workers:

Male:

Female:

Total Employment:

Engaged Subcontractors’ Profile:

Name of Sub-contractors
(if any):

Scope of Work and Project Cost:

No. of Workers:

PCAB License:

Date of Validity:

Date of DOLE Registration:

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:

Project Classification:

Total Project Cost:

Date of Estimated Start/Execution of the project:

Duration of the project (Pls. state the number of calendar days)

Estimated number of workers to be deployed:

Phase/Stage:

Construction Activity

Estimated No. of Workers:

Brief Description of Activities/Work Flow:

OSH Personnel assigned to the project:

Designated Safety Officers: (1 SO2: 1 - 9 workers; 2 SO2: 10 - 99 workers; 3 SO2 / 2 SO3: 100 - 199 workers;)

Name:

Designation:

Date of Training:

Designated First Aider: (1 FA: 1 - 9 workers; 2 FA: 10 - 99 workers; 3FA: 100 - 199 workers;)

Name:

Date of Training:

ID Validity:

Other OH personnel: (2 PT NURSE: 51 - 99 workers; 1 FT NURSE: 100 - 199 workers;)

OH Nurse

Name:

Date of 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:

Profile of the person who prepared the CSHP:

Name:

eSignature: (if applicable)

Educational Background:

Work Experience in OSH:

Other Qualifications:

Submitted By:

Name:

Position:

eSignature: (if applicable)

1.0 Statement of Commitment to Comply with OSH Requirements:

Contractor’s Authorized Official

eSignature: (if applicable)

3.0 Project Details:

i. Specific name of project and name of owner:

ii. Project Owner:

ii. Location of the project:

iii. Classification of the project

General Building Construction

General Engineering Construction

Specialty Trade Construction

Others(Please Specify):

iv. Name of the general constructor:

v. Name of project manager/contact number/email:

vi. Name of resident engineer, if any

vii. Name and Classification of Constructors :

Name of contractor/subcontractor

Classification

ix. Number of workers

1st shift:

Male:

Female:

2nd shift:

3rd shift:

x. Work hours, including shift

1st shift:

From:

To:

2nd shift:

3rd shift:

xi. Estimated number of heavy equipment:

Backhoe:

Dozer:

Loader:

Dump truck:

Crane:

Grader:

Others(Please Specify):

xii. Projected dates of commencement and completion

Start Date:

End Date:

Days to Complete:

xiii. Name and address of emergency health provider

xiv. Total project cost

xvi. Itemized cost on OSH

Amount:

4.1 Composition of Construction Safety and Health Committee (CSHC)

a. Project Manager or his representative as the chairperson

b. General Construction Safety and Health Officer/s

Safety Officer:

c. Construction Safety and Health Officer/s from Subcontractors

Safety Officer

Company

d. Occupational Health Personnel

First Aider:

Company:

First Aider:

Company:

AHAS

Dentist:

Company:

Nurse:

Company:

Physician:

Company:

e. Workers’ representative

Name

Designation

Company

4.2 Duties of the CSH Committee

Specific Day of Safety Meeting Every Month:

Type of OSH Training/Orientation	OSH Personnel who conducts/supervises the training/orientation	Number of Attendees
Type of OSH Training/Orientation		Male	Female

5.0 Emergency Occupational Health Personnel and Facilities

Construction Stages	Our number of workers during this stage	Health Personnel & Facilities
Construction Stages	Our number of workers during this stage	Health Personnel	Facilities

6.1 Workers Safety and Health Orientation/Trainings

The assigned Safety Officer:

List the workers who have undergone the DOLE-prescribed safety and health training and orientation below

Name	Title of training attended	Remarks

6.2 Specialized Instruction and Trainings

List below the inventory lists of workers who hold critical occupations and attended the specialized training

Name	Title of training attended	Remarks

7.1 Responsible for the Toolbox Meeting

Name of Supervisor	Time of Toolbox Meeting (indicate shift, e.g. 1st, 2nd, 3rd )	Means of Documentation (attach sample instrument)

8.1 Persons responsible for conducting the investigation

Following person/s will be assigned to conduct an accident/incident investigation:

All accidents	All incidents/near miss	Illnesses

9.0 Personal Protective Equipment (PPE)

Item No.	Type of PPE	Quantity needed	Unit Price	Total Cost
B7.2	SAFETY HARD HAT	13	350	PHP 4,550.00
	SAFETY SHOES	13	750	PHP 9,750.00
	SAFETY VEST	13	150	PHP 1,950.00
	SAFETY GLOVES	13	40	PHP 520.00
	SAFETY BOOTS	13	350	PHP 4,550.00
	SAFETY HARNESS
	RAIN COAT

11.1 Inspection and Maintenance of Safety Signages

The person responsible for this program

Designation

eSignature: (if applicable)

The person in charge in inspecting

He/She is/are:

Specific inspection will be carried out

14.1 Major Activities

14.2 Hazards Identified

a. Physical Hazards

b. Chemical Hazards

c. Biological Hazards

Blood or other body fluids

Bacteria and viruses

Insect bites

Others (Please Specify)

Fungi

Plants

Animal and bird droppings

d. Ergonomic Hazards

Poor lighting

Poor Posture

Excersion of force

Others (Please Specify)

Frequent lighting

Repetitive motion

Awkward movement

14.3 Safe Work Practices

Enumerate below the safe work practices that you intend to perform relative to the hazards you previously identified above.

18.0 Working Hours & Break Time

The work schedule will be on (please check on the boxes that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Check on the shift and indicate the work hours for the shift that applies.

1st Shift from to

2nd Shift from to

3rd Shift from to

Check on the shift and indicate the break for the shift that applies.

1st Shift from to

2nd Shift from to

3rd Shift from to

22.0 Penalties/Sanctions

Safety Violations	1st offense	2nd offense	3rd offense

UPLOAD REQUIRED DOCUMENTS

ACTION

ONLINE APPLICATION OF CSHP

(Fill up CSHP Application form; N/A if not applicable)

CREATE DIGITAL CSHP

Department of Public Works and Highways

APPLICATION FORM FOR THE EVALUATION/PROCESSING OF CONSTRUCTION SAFETY & HEALTH PROGRAM (CSHP)

A. Company Profile/License/Registration of Main/General Contractor :

Engaged Subcontractors’ Profile:

B. Project Profile/Description :

Estimated number of workers to be deployed:

OSH Personnel assigned to the project:

Other OH personnel: (2 PT NURSE: 51 - 99 workers; 1 FT NURSE: 100 - 199 workers;)

If Heavy Equipment will be used in the Project:

Profile of the person who prepared the CSHP:

Submitted By:

1.0 Statement of Commitment to Comply with OSH Requirements:

3.0 Project Details:

4.1 Composition of Construction Safety and Health Committee (CSHC)

4.2 Duties of the CSH Committee

5.0 Emergency Occupational Health Personnel and Facilities

6.1 Workers Safety and Health Orientation/Trainings

6.2 Specialized Instruction and Trainings

7.1 Responsible for the Toolbox Meeting

8.1 Persons responsible for conducting the investigation

9.0 Personal Protective Equipment (PPE)

11.1 Inspection and Maintenance of Safety Signages

14.1 Major Activities

14.2 Hazards Identified

a. Physical Hazards

b. Chemical Hazards

c. Biological Hazards

d. Ergonomic Hazards

14.3 Safe Work Practices

18.0 Working Hours & Break Time

22.0 Penalties/Sanctions

ONLINE APPLICATION OF CSHP

(Fill up CSHP Application form; N/A if not applicable)

CREATE DIGITAL CSHP

Department of Public Works and Highways

APPLICATION FORM FOR THE EVALUATION/PROCESSING OF CONSTRUCTION SAFETY & HEALTH PROGRAM (CSHP)

A. Company Profile/License/Registration of Main/General Contractor :

Engaged Subcontractors’ Profile:

B. Project Profile/Description :

Estimated number of workers to be deployed:

OSH Personnel assigned to the project:

Other OH personnel: (2 PT NURSE: 51 - 99 workers; 1 FT NURSE: 100 - 199 workers;)

If Heavy Equipment will be used in the Project:

Profile of the person who prepared the CSHP:

Submitted By:

1.0 Statement of Commitment to Comply with OSH Requirements:

3.0 Project Details:

4.1 Composition of Construction Safety and Health Committee (CSHC)

4.2 Duties of the CSH Committee

5.0 Emergency Occupational Health Personnel and Facilities

6.1 Workers Safety and Health Orientation/Trainings

6.2 Specialized Instruction and Trainings

7.1 Responsible for the Toolbox Meeting

8.1 Persons responsible for conducting the investigation

9.0 Personal Protective Equipment (PPE)

11.1 Inspection and Maintenance of Safety Signages

14.1 Major Activities

14.2 Hazards Identified

a. Physical Hazards

b. Chemical Hazards

c. Biological Hazards

d. Ergonomic Hazards

14.3 Safe Work Practices

18.0 Working Hours & Break Time

22.0 Penalties/Sanctions

Upload or drag application files here

Upload or drag Letter of Intent files here

Upload or drag CSHP files here

Upload or drag Registration under OSHS Rule 1020 files here

Upload or drag Valid PCAB License files here

Upload or drag NOA files here

Upload or drag Valid Certificate of Inspection files here

Upload or drag Certificate of Completion files here

Upload or drag Valid NC files here

Upload or drag Valid MOA files here