Non-Construction
Contractor Selection Questionnaire
Please include, where requested, any supporting documents marked clearly on all
enclosures the name of your Company and the number of questions to which they
refer. Large documents may be provided in electronic format.
This document will be reviewed every 2 years.
The completed questionnaire should be returned to:
[Faculty/Service]
Staffordshire University
College Road
Stoke on Trent
ST4 2DE
The information you give will be treated as confidential
CONTRACTOR SELECTION QUESTIONNAIRE
Section 1
Company Information
Please provide the following details about your Company
Name:
Address:
Turnover:
Tel No.
Email:
Web address:
Fax:
No of Employees:
Companies House Registration:
Date of Formation or Age of
Company:
Names of Directors:
Please confirm whether any of the above named Directors have been convicted
of an offence concerning their professional conduct:
Yes
No
1
2
Please attach details of your organisation’s experience in the
area that you are tendering for, include details of previous
contracts and referees.
Please give details of 2 referees:
Referee 1
Referee 2
Name:
Name:
Company:
Company:
Address:
Address:
3
Company’s main area of work:
4
Is your organisation or any member of staff a member of any
trade or professional organisation?
If so please provide details of membership of any such
organisation.
5
Insurance:
Insurer:
Employer’s Liability Insurance held:
Enclose a copy of your policy
Policy No:
Extent of Cover:
Attached
Yes
No
CONTRACTOR SELECTION QUESTIONNAIRE
Insurer:
Public Liability (3rd party) insurance held:
Enclose a copy of your policy
7
Extent of Cover
(minimum cover
£10m)
Do you anticipate using subcontractors? If so, how do you assess their health
and safety competence?
Section 2
8
Policy No:
Health & Safety Information
Please provide the names and job titles of those people in your organisation
with the following responsibilities: The person who has ultimate responsibility
for health and safety:
Name:
Job Title:
The person responsible for the day to day management aspects of on-site
work:
Name:
Job Title:
CONTRACTOR SELECTION QUESTIONNAIRE
9
If you employ five or more employees, please attach a copy of
your company’s most recent health and safety policy (including
general statement of intent, organisation for health and safety
and working arrangements).
Contractors that do not have health and safety policies must
demonstrate their commitment to health and safety by having
the most senior person in the organisation sign and date the
‘Commitment to Health and Safety at Work’ (attached) and
return a copy to the University.
Give details of how your health and safety policy is maintained:
10
Competent Health & Safety Adviser
State the name of the person or people who provide your competent health
and safety advice.
Name:
Address:
Tel No:
Email:
11
Describe their health and safety qualifications, experience or relevant training
that enables them to undertake this responsibility:
12
If your competent advice is from outside your Company, describe the role they
play in the management of health and safety in your Company and describe
the capacity in which your Company has employed them in the last year.
CONTRACTOR SELECTION QUESTIONNAIRE
13
Please describe any other sources you may use to get health and safety
information:
14
How do you monitor the health and safety performance of your:
 Company:
 Employees:
 Sub-Contractors:
15
How do you ensure that employees are kept up to date on health and safety
matters?
16
How do you assess sub-contractors’ health and safety competence?
(e.g. Contractor Selection Questionnaire - please attach copy)
17
How do you ensure that plant and equipment is in a safe and useable
condition?
18
Please enclose copies of any six assessments undertaken for
similar projects:

General Risk Assessments, as required by the
Management of Health and Safety at Work Regulations
1992.

Safety Data Sheets and COSHH Assessments for all
substances that you propose to use (if applicable).

Any other relevant assessment (e.g. manual handling,
noise)
Attached
Yes
No
CONTRACTOR SELECTION QUESTIONNAIRE
19
Health & Safety Training, Information and Instruction
Attached
Yes
No
How does your Company provide relevant health and safety
training, information and instruction to its employees:
20
21
22
Attach copies of training records for your company employees
likely to work on Staffordshire University Sites.
Does your Company provide induction training for new
starters?
Does your Company provide written instructions for your
employees e.g.: a safety manual. If yes, attach copies of
instructions relevant to work on Staffordshire University Site.
Describe health and safety training given to Managers in the last three years.
Describe the health and safety training given to workers in the last three years.
What are your plans for training during the next twelve months?
23
Asbestos
Yes
No
Have you trained your employees about asbestos, where it
may be found and what it might look like?
Have your employees been trained in the action to take if
they find materials they suspect may contain asbestos?
If YES (in either case) attach evidence of training.
24
Attached
Yes
No
Accident Reporting
Describe how your company reports and investigates accidents.
CONTRACTOR SELECTION QUESTIONNAIRE
Complete the following table of accident statistics
Year
Fatal
Major Injury Non Reportable
+ over 7 day
This year (to date)
Last year (full year)
Year before last (full
year)
Give an example of any of the above accidents which were investigated and
what actions, if any, arose from that investigation.
25
Please provide details of any accidents/incidents to employees and non
employees reported by or on behalf of your organisation to the Health & Safety
Executive (HSE) during the last 3 years (as required by the Reporting of
Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).
26
Have any enforcement notices been issued or legal
proceedings taken against your organisation by the Health &
Safety Executive (HSE) in the last 3 years? If so please give
details:
27
28
Yes
No
(Please note that this will be checked against the
HSE prosecutions and notices database)
How do you ensure health and safety procedures are followed by staff and
sub-contractors?
Please provide details of how often and by whom safety inspections will be
carried out.
CONTRACTOR SELECTION QUESTIONNAIRE
29
Is your Company a member of any health and safety
organisations e.g.: ROSPA, British Safety Council, or IOSH?
Yes
No
Yes
No
If so give details:
Is your company a member of the North Staffordshire
Health & Safety Group? (www.nshsg.org.uk)
If yes, how many meetings/events have you attended over
the last twelve months?
30
I certify that the information supplied is accurate, to the best of my knowledge. I
understand that false information could result in my Company’s exclusion from the
Approved contractors List.
Name:
Signed:
Position:
Dated:
Before returning this questionnaire, please ensure that you have:
* Answered all questions
* Enclosed all documents
COMMITMENT TO HEALTH AND SAFETY AT WORK
Our Company is committed to ensuring that the health, safety and welfare
of my employees, University staff, students and visitors is not adversely
affected by the work my company carries out.
We will:
 Control health and safety risks arising from our work activities.
 Consult with our employees on matters affecting their health and safety.
 Provide and maintain safe plant and equipment.
 Ensure safe handling, use and storage of substances.
 Provide the necessary information, instruction training and supervision to
our employees and ensure they are competent to do the work given to
them.
 Endeavour to prevent all accidents and cases of work-related ill health.
 Provide a safe and healthy place of work.
 Review and revise this commitment as necessary and at intervals not
exceeding two years.
 Provide adequate resources to ensure health and safety is managed
properly.
Name:
Position:
Signature:
Dated: