OCCUPATION HEALTH AND SAFETY
MANAGEMENT SYSTEM AND
COMPLIANCE QUESTIONNAIRE
Document Reference No: CMA 100 FORM
INTRODUCTION
Service providers are required to verify their responses noted in this questionnaire by providing evidence of their
ability and capacity in relevant matters
Please note you are required to provide detail, comment or attachments where indicated.
The objective of this questionnaire is to provide an overview of the status of an organisations OHS management system and
that the organisation meets its OHS responsibilities under the OHS Act 2004. By confirming this, the Mallee CMA meets its
responsibilities under the OHS Act 2004.
This questionnaire is to be completed and submitted with all tender responses or quotes. Organisations must be compliant
prior to their approval of works or services.
If you intend to subcontract any element of the proposed works or services, then you become an Employer and are no longer
a sole operator under the Mallee CMA OHS requirements.
Questions without a YES/NO Checkbox are mandatory unless otherwise advised
CERTIFICATION DETAILS
Organisation Name:
Mallee groundwater monitoring 2015/16 and 2016/17
Contract No:
15.1388
Metadata
Project / Contract Name
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2.0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 1 of 7
SECTION A – OHS SYSTEM MANAGEMENT QUESTIONNAIRE
1. OHS Compliance
1.1
Has the organisation ever been convicted of an occupation
health and safety offence, or are any proceedings
underway or pending?
Yes
No
Provide Details:
1.2
Has your organisation completed this form in the previous
24 months?
Yes
No
1.3
Does the Mallee CMA have your current insurance details?
Yes
No
Provide up to date
insurance details on page
4 and copies of
Certificates of Currency
1.4
Has your organisation lodged OHS documentation for
review by the Mallee CMA in the previous 24 months?
Yes
Go to SECTION B
No
Continue to question 2
Yes
Go to SECTION B
No
Continue to question 3
2. Office Based Project Activity
2.1
Is the activity you are undertaking for the Mallee CMA
solely office based? For example R&D, report writing, data
interpretation etc. which will be undertaken within your
workplace and not require you to leave your workplace?
3. OHS Policy and Management
3.1
Provide a copy of your organisation’s written workplace health and safety policy
3.2
Does your organisation have an OHS Management
System certified by a recognised independent authority
(e.g. Safety MAP, NSCA 5 Star System, or International
Safety Rating System)? (Not mandatory).
Yes
No
Provide Details:
Provide a copy of the contents page of your organisation’s OHS management system
manual/plan.
3.4
Provide evidence that health and safety responsibilities are clearly identified for all levels
of staff.
Metadata
3.3
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2..0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 2 of 7
4. Safe Work Practices and Procedures
4.1
Provide a summary list of procedures and/or instructions that demonstrates that the
organisation has prepared safe operating procedures or specific safety instructions
relevant to its operations.
4.2
Does the organisation have any Permit to Work Systems
(dependant on type of works/services)
Yes
No
Provide a summary list of
listings and/or permits
(please attach separately)
4.3
Provide a copy of a standard ‘Incident Report’ form from the organisation’s incident
investigation procedure
4.4
Are there procedures for maintaining, inspecting and
assessing the hazards of plant, operated/owned by the
organisation
(dependant on type of works/services)
4.5
4.6
Are there procedures for storing and handling chemicals
and/or dangerous/hazardous substances
(dependant
on type of works/services)
Yes
No
Provide details:
Yes
No
Provide details:
Detail the organisation’s procedure for identifying, assessing and controlling risks
associated with manual handling?
5. Health and Safety Workplace Inspection
Provide details to demonstrate that health and safety inspections are regularly
undertaken at your workplace and worksites
5.2
Provide details and attach evidence that demonstrates the use of standard workplace
inspection checklists when conducting health and safety inspections
Metadata
5.1
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2..0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 3 of 7
6. Subcontractors
6.1 Do you intend to sub-contract any element of the proposed
works?
Yes
No
You are required to ensure that
subcontractors meet the Mallee CMA
OHS requirements. You are also
required to provide the Mallee CMA
with the subcontractor’s JSA/WSMS or
Risk Assessments (as applicable) for
the sub contracted element.
IF YOU ARE A SOLE OPERATOR SKIP TO SECTION B
7. Health and Safety Consultation
7.1
Is there a workplace health and safety committee?
Yes
Provide details:
No
7.2
Provide details and attach evidence that details employees involvement in decisions made
over OHS matters
7.3
Are there employee elected health and safety
representatives?
Yes
Provide details:
No
8. OHS Performance Monitoring and Reporting
8.1
Provide detail of the procedure by which employees can report near misses/hazards in the
workplace.
8.2
Provide details of the organisation’s system for monitoring, recording and analysing health
and safety performance statistics
8.3 Provide details to demonstrate that employees are regularly provided with information on
health and safety performance in your organisation
9. OHS Training
Describe how health and safety training is conducted in your organisation
9.2
Provide evidence to demonstrate that a record is maintained for all training and induction
programs undertaken for employees in your organisation.
Metadata
9.1
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2..0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 4 of 7
SECTION B – DETAILS OF INSURANCE
Complete this section and attach Certificates of Currency.
Public Liability Policy
Insurer:
Expiry Date:
Policy No:
Level of Indemnity
(in accordance with Project Brief)
Product Liability
Insurer:
Expiry Date:
Policy No:
Level of Indemnity
(in accordance with Project Brief)
WorkCover Policy
Insurer:
Employee/Policy No:
Expiry Date:
Professional Indemnity Policy
Insurer:
Expiry Date:
Policy No:
Level of Indemnity
Metadata
(in accordance with Project Brief)
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2..0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 5 of 7
SECTION C – Training / Licences / Certificates
Complete section below. Include certificates/licences relevant to tasks being undertaken on site (i.e. forklift, drivers, electrical,
plant, diving etc.) OR
Attach photocopies of Licences / Certificates – If so, you do NOT need to complete this section.
Contractors Construction Training
N/A
Worksafe Construction Induction
Licence / Certificate:
Reg No.:
Licensee:
State of Issues:
Licence No.:
Issue Date:
Expiry Date:
Expiry Date:
Licence / Certificate:
Reg No.:
Licensee:
State of Issues:
Licence No.:
Issue Date:
Expiry Date:
Expiry Date:
N/A
SECTION D – AUTHORISED CONTRACTOR CONSULTANT
REPRESENTATIVE
I have read and understood the document CMA 101 FORM - Guidelines for completing the Occupational Health and Safety
Management System Questionnaire. The information provided in this questionnaire is an accurate summary of the
organisation’s Occupational Health and Safety Management System.
I certify that the information provide on behalf of my organisation is true and correct.
Name:
Metadata
Position Title:
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2..0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 6 of 7
Signature
Date:
/ /
SECTION E – MALLEE CMA REPRESENTATIVE
I have checked the questionnaire and supporting documents for compliance in accordance with the guidelines.
Name:
Position Title:
Signature
Date:
/ /
SECTION F – MALLEE CMA OHS COORDINATOR
I certify that the Contractor/Service Provider meets the Mallee CMA OHS requirements.
Name:
Position Title:
Signature
Date:
/ /
OFFICE USE ONLY:
Entered in Contractor OHS Database
Date:
/ / /
Metadata
File Action: Original to the Safety Officer. Copy in the Service Provider (OHS) Compliance file.
Approved by
Owner/Custodian
Date of First Issue
Version
Search terms
Manager Corporate Services
Last Updated
Manager Corporate Services
Replaces
May 2015
Review Date
2.1
Review Trigger
OHS Management system, questionnaire, contractor, sole operator
June 2015
2..0
May 2017
CMA 048 PRO
Reference: CMA 100 FORM
Page 7 of 7