Revised Form: CSHP Form 1A-2023:
Date of Revision: 30 April 2023
Page 1 of 3
APPLICATION FORM
FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Department of Labor and
Employment
REGIONAL OFFICE NO.
________
Legal Bases:
1. Presidential Decree No. 442, as
renumbered
2. Republic Act No. 11058
3. Department Order No. 198, Series of 2018
Type of Construction Project:
_____DPWH project
_____Other Public/private construction project
(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 Address of the Project
253 SHAW BLVD. WACK-WACK MANDALUYONG CITY
Complete Name of the
Company/Main/ General
Contractor/Project Owner
JANGHO CURTAINWALL
PHILIPPINES INC.
Tel. No: 09179132608
Fax No. ___________________________________________________
Name of Project
Manager/Owner/ Contact Person:
-
LI WEI
Contractor’s PCAB/JV License
No: 42393
Number of workers:
Male: 6 Female: 3 Total employment: 9
Date of Validity: JULY 1, 2023 to
OCTOBER 30, 2024
Engaged Subcontractors’ Profile
Name of Subcontractors (If any)
1.
2.
3.
4.
5.
Scope of
Work and
Project
Cost
No. of
Workers
PCAB License
Date of Validity
Date of DOLE Registration
APPLICATION FORM
FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Department of Labor and
Employment
REGIONAL OFFICE NO.
________
6.
7.
(Use separate sheet, if necessary)
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:
253 Shaw blvd. Wack-Wack Mandaluyong City
Name of Project Owner:
SPI PROPERTY DEVELOPERS INC
Tel. No: (632) 8370-2700
Fax No: _____________
Email : _____________
Project Classification:
Estimated No. of
Workers to be
deployed in the
project:
50 Workers
Total Project Cost:
176,800,000,.00
(Workforce of the
project
to
include workers
of
the subcontractor/s)
Date of Estimated Start/Execution of the project:
Febuary /15 /2021
Month
Day Year
Duration of the project (Pls. state the number of calendar days)
Febuary 14, 2027
APPLICATION FORM
FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Department of Labor and
Employment
REGIONAL OFFICE NO.
________
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
FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Department of labor and Employment
REGIONAL OFFICE NO. ______
OSH Personnel assigned to the project
Designated First Aider:
Name
Date of training
CORPUZ, EDWIN C.
November 13, 2015
Name
KENDUTAN, DAVE E.
Designated Safety Officers:
Date of training
Dec. 5, 2023
ID Validity
Dec. 4,2025
Please attach a photocopy of the Certificate of First-Aid Training and
valid First Aid ID from Phil Red Cross, DOH, Bureau of Fire and
DOLE- Accredited TVIs with TESDA registered EMS and other
DOLE-Accredited first aid training provider
(Please attach photocopy of Certificate of Completion on the Basic
OSH Course for Construction Site Safety Officers issued by DOLEBWC accredited Safety Training Organizations or recognized
institution)
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 Owner/Contractor
Position
Date
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