Document Reference No: CMA 101 FORM

1. Introduction

The Mallee CMA has a responsibility under the Occupational Health and Safety Act (Vic) 2004 for the operation of service providers (contractors and consultants) when undertaking work on the Authority’s behalf. The aim of this form is to help evaluate the status of a potential service provider’s health and safety system prior to engaging them to perform work on behalf of the Mallee CMA.

This document has been developed using the WorkSafe Victoria “Guidance Note – Contractor Management - June 2011” It can be used to help evaluate the status of a potential service provider’s health and safety system prior to engaging them to perform work on behalf of Mallee CMA and prior to completing the OHS Management System and Compliance Questionnaire (MSQ).

This document may be used as part of the evaluation of the service provider’s MSQ.

The service provider is to be asked to show evidence that systems exist in order to verify their compliance.

Section A

Please read and complete each and acknowledge by marking the box.

1. OHS compliance
Conviction of Health and Safety Offence and Current Insurance
If conviction reported, determine:
  • Nature and circumstances of incident
  • Corrective actions undertaken
Insurance must be current and certificates of currency for Public and Product Liability and WorkCover supplied.
2. Office based project activity
If the service being provided for the Mallee CMA is solely office based; for example R&D, report writing, data interpretation etc. which will be undertaken within the service provider’s workplace and not require the service provider to leave their workplace; then they should skip to Section B. They should provide a JSA or risk assessment for office based work.
OHS induction is not required for office based project activity.
3. OHS policy and management
Company Health and Safety Policy
The Policy provided by the potential service provider should:
  • Be signed by the CEO or equivalent
  • Outline clear statement of objectives
  • Show commitment to improve performance
  • Be relevant to company operations
  • Be reviewed on a regular basis

Certified OHS Management System
Certification demonstrates that the potential service provider meets minimum standards, verified by an independent party. These may include:
  • SafetyMAP (three levels of certification)
  • NSCA 5 Star System
  • International Safety Rating System
Certificates should be available for perusal
OHS Management System or Plan
The company OHS Manual or Plan should include as a minimum:
  • Management health and safety responsibilities
  • General occupational health and safety procedures
  • Safe work procedures relevant to the company operations
  • Public safety procedures
  • Issue resolution and OHS consultation mechanisms

Health and Safety Responsibilities
Health and safety responsibilities in the company should be documented and may comprise:
  • OHS responsibility statements
  • Part of employee’s job description
  • Part of formal and informal performance appraisal
Line Managers and supervisors should be formally held accountable for health and safety performance of their employees.
4. Safe work practices and procedures
Safe Work Procedures
The potential service provider should be able to demonstrate safe work procedure which:
  • Are relevant to company operations
  • Contain a description of the tasks and associated hazards
  • Outline control measures and methods to minimize health and safety risks
  • Make reference to any relevant Legislation, Codes of Practice or Australian Standards

Safe Work Permits
Where relevant, the potential service provider should be able to demonstrate safe work permits for the following types of work:
  • Work in confined spaces (Confined Space Entry Permits)
  • Hot Work (Hot Work Permit)
  • Lockout permits (plant, electrical systems steam)

Incident Reporting and Investigation
Potential service providers should be able to provide evidence of the following:
  • Incident report and investigation form
  • Incident investigation procedure
  • Evidence of completed investigation forms.

Plant Safety
The potential service provider should have mechanisms in place for the identification of hazards, assessment of risks and the implementation of control measures associated with plant. This may include:
  • Documented risk assessments for relevant plant or risk assessment procedure
  • Copy of plant operator licences, permits
  • Register of plant requiring registration
  • List of persons responsible for undertaking plant risk assessments
  • Plant maintenance and inspection forms
  • Pre-start daily safety inspection forms for plant
  • Plant fault reporting system and forms.

Chemicals and Dangerous/Hazardous Substances
The potential service provider should provide evidence demonstrating safe handling and storage of hazardous substances:
  • Manifest of register of chemicals used by the company
  • Material Safety Data Sheets (MSDS) for chemicals used
  • Safe handling procedures, including personal protective equipment, storage and disposal
  • Relevant training documentation.

5. Health and safety workplace inspection
Regular Inspections
The potential service provider should provide evidence of:
  • Workplace inspection schedules
  • Completed inspection reports
  • Types of inspections undertaken

Standard Inspection Checklist
Copies of the types of inspection checklists used by the potential service provider
Hazard Reporting from Potential Service Provider
Evidence may include:
  • Document hazard reporting procedure and forms

6. Sub contractors
The Mallee CMA and you have a responsibility to ensure the safe work practices of a sub-contractor.
Evidence may include:
  • Completion of your organisation’s OHS compliance form by the sub-contractor
  • You must provide the sub-contractor’s JSA/WSMS or Risk Assessment for the sub-contracted element of the works/project

7. Health and safety consultation
Health and Safety Committee
Evidence may include records which show:
  • Structure of committee
  • Meeting schedule
  • Minutes of meetings

Employee Consultation
The potential service provider should provide evidence of:
  • List of employee health and safety representatives
  • Documented procedures for consultation and dissemination of information
  • Employee involvement in inspections, accident investigations

8. OHS performance monitoring
Safety Performance Statistics
Evidence may include:
  • Reports on company health and safety injury trend data
  • Performance targets established (e.g. lost time, injuries, person days lost)

Health and Safety Performance Information
Evidence of information provided to employees:
  • Records of who receives reports
  • Types of reports produced

9. OHS training
Health and Safety Training
The potential service provider should be able to demonstrate evidence of:
  • Records of training and competencies of employees (licences, permits, certificates
  • Records of ‘on the job’ training
  • Tool box meetings conducted
  • Induction training program

Section B

10. Details of insurance
The potential service provider is to provide copies of Certificates of Currency for:
  • Public Liability
  • WorkCover (relevant to jurisdiction)

Section C

The potential service provider is to provide details or copies of any certificates/licences relevant to tasks being undertaken on site. These may include, but are not limited to:
  • Contractors Construction Training
  • Worksafe Construction Induction
  • Forklift licence

Section D

Service Provider Name:
Review conducted by:
Date: / / /

File Action: A completed copy of this form to be filed with the OHS documents in the program file

Metadata / Approved by / Manager Corporate Services / Last Updated / June 2015
Owner/Custodian / Manager Corporate Services / Replaces / 1.0
Date of First Issue / Oct 2013 / Review Date / May 2017
Version / 2 / Review Trigger / CMA 048 PRO
Search terms / Contractor, service provider, OHS, Management systems / Reference: CMA 101 FORM

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