NIS a.d. Novi Sad
(Block _______/ O.U. of NIS j.s.c. Novi Sad)
Date:
Number:
HSE
Qualifying Questionnaire No. __________
This evaluation form is used by the Company (NIS j.s.c. Novi Sad) in order to determine to what extent the
Contractor meets the criteria in terms HSE* for safe and environmentally-friendly behaviour within its business. The
questionnaire includes a wide range of questions related to HSE, and based on given answers, the Company will
determine whether the Contractor will qualify and obtain the status of "The Qualified Contractor in terms of HSE".
The requirements of legal regulations on Occupational Safety and Health, Environmental Protection and Fire
Protection are mandatory as a minimum.
1.
Information about Contractor
Full name of Contractor’s Company: ___________________________________________________
Full address: _________________________________________________________________________
ID number: ______________________________ TIN: _____________________________________
Business activity: __________________________ Business activity code: _____________________
Contact person: _______________________________ Function: ____________________________
Telephones: ____________________ Fax: _________________ E-mail: _______________________
Activity field for which you are applying:
____________________________________________
State previous contracts with the Company as per reference number of NIS j.s.c. Novi Sad (if any):
_______________________________________________________________________
________________________________________________________________________________
2.
Profile of the Contractor’s Company
2.1 Type of activities performed by the company – description of services
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.2 Details about the Organization of the Company
Key positions
Information about existence /
Headcount
Management
Line managers (managers/supervisors)
Employees
Total Headcount
Engaged third parties
Systematization of work positions/excerpt from the systematization of work
positions – Description of work
Decision on appointment of Persons responsible for Occupational Safety and
Health (copy)
The total number of man-hours (monthly/annually)
2.3 The Structure of Injuries in the Company
Injuries/illnesses in the last 12 months
Fatalities
Injuries that cause disability
Injuries with lost days
Injuries with medical treatment
Injuries without lost working hours
Provide evidence by enclosing appropriate OSH record forms (Form 3 or Form 4)
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HSE* - generally accepted abbreviation coming from English words "Health, Safety, Environment“. The synonym for HSE operations used in
organizational units of the Company is Industrial and Environmental Safety, Occupational Safety and Health.
2.4 HSE Acknowledgements and Achievements of the Company
HSE recognition/Achievements
State the basic facts on recognition
Acknowledgements
Certificates (ISO 9001, ISO 14001, OHSAS
18001)
Awards (to the Company)
Awards (to Employees)
The person responsible for HSE
Provide evidence by enclosing relevant elements/documents
3.
General HSE system
3.1
HSE Policy
Does your Company have HSE Policy in a written form?
Does your Company have a written HSE Training Policy?
Does your Company have a written Policy concerning the prohibition of consumption/use of
alcohol, narcotics and opiates?
Are these policy statements analysed and explained in the Introductory HSE Training of
employees?
Provide evidence by enclosing relevant elements/documents
3.2
Roles and Responsibilities in respect of HSE
Are your employees trained so that they understand the legal obligations in terms of HSE?
Familiar with obligations in the field of HSE (e.g. a separate Annex to the Labour contract):
Management
Line managers (managers/supervisors)
Employees
Subcontractor’s employees
Provide evidence by enclosing relevant elements/documents
3.3
Introductory training and specialized HSE training
Does your company have:
Program of Introductory HSE Training/HSE Training?
Documents/records of implemented trainings?
The process of legal recording of HSE trainings of employees?
Do trainings include:
Explanation of safety working procedures for equipment /activities?
Explanation for proper use of protective clothing /equipment?
Provide evidence by enclosing relevant elements/documents
3.4
Selection of Contractors/Subcontractors
Does your company have HSE capacity assessment procedures for
Contractors/Subcontractors?
Is the performance of Contractor/Subcontractor regularly monitored in relation to HSE during
the implementation of activities (records, observations, controls etc.)?
Provide evidence by presenting processes/records for engagement and monitoring of
Contractors/Subcontractors
3.5
Health Condition Monitoring
Does your company have an established system for monitoring health condition of employees
in terms of identified risks and hazards which they might be exposed to?
If your answer to the previous question is "Yes", in which time interval do you implement legal
medical examinations of employees?
(Please circle the interval/number of years)
1
2
3
4
5
Do all engaged employees have required/valid medical examinations?
Provide evidence by enclosing the report on monitoring the health status of employees
(without disclosing personal data related to the health of employees)
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Yes
No
Yes
No
Yes
No
Yes
No
Yes
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No
3.6
Insurance
Yes
Do you have an insurance policy of employees for occupational injuries?
Do you have an insurance policy on workplace for certain facilities/locations/plants?
Proof of registration of engaged employees for mandatory insurance (M form)
Do you have an additional insurance policy for vehicles/mechanization/equipment?
Provide evidence by enclosing the copies of insurance policies or appropriate documents
No
3.7
Plants and Equipment
Yes
No
When using plants and equipment either in your property or provided by NIS j.s.c. Novi Sad and/or a third
party (leasing, hiring, lending etc.) do you have established systems to meet the following requirements:
All equipment and plants which you plan to engage during implementation of activities for the
purposes of NIS j.s.c. Novi Sad have safety equipment prescribed by positive regulations (e.g.
machinery safety guards, protection around rotating parts, grounding, spark arrestors, exprotection, etc.)
All equipment, plants and materials which you plan to engage during implementation of
activities for the purposes of NIS j.s.c. Novi Sad are in compliance with requirements of local
legislation of the Republic of Serbia, and/or related standards and technical norms (e.g.
compliance with standards, commands, instructions, safety lists etc.)
All equipment and plants which you plan to engage during implementation of activities for the
purposes of NIS j.s.c. Novi Sad have valid expert findings/certificates
Employees in charge of equipment, plants and materials you plan to engage during
implementation of activities for the purposes of NIS j.s.c. Novi Sad have undergone training to
safely operate
Your employees whom you plan to engage during implementation of activities for the
purposes of NIS j.s.c. Novi Sad possess appropriate evidence (certificates/licenses) to
operate the relevant equipment/they are professionally trained
Provide evidence on existence of Guidelines for safe and healthy work (GSHW) to operate given equipment
and certificates on professional trainings
3.8
Management and Investigation of Events/Incidents/Accidents
Does your company have a system/procedure for reporting/recording incidents/ accidents?
Does your company have a system/procedure for investigating causes of incidents/accidents?
Does your company have a system/procedure for reporting incidents/accidents to the
responsible person at the location where the works are being executed?
Did your company have some of these accidents in the last 12 months (OSH record forms)
which resulted in:
Fatalities
Serious Events (big material damage, collective injury etc.)
Injuries with lost days
Accidents with medical intervention
Near misses (Events/Incidents/Accidents)
Incidents with damage to property/minor material damage
Is a court dispute initiated against your company in connection with violation of HSE
regulations?
Did your company determine the causes of their emergence during the investigation of
aforementioned Events/Incidents/Accidents in the last 12 months?
Causes:
Roles and responsibilities of employees
Lack of staff training
Faulty equipment
Lack of instructions for safe and healthy work
Other____________________________________(write yourself)
Provide copies of records/documents of Event/Incident/Accident Management
3.9
Personal Protection Equipment (PPE)
Has your Company identified work positions required for PPE?
Does your Company provide/give all employees for usage relevant PPE free of charge?
Is PPE provided in accordance the law, regulations and risk assessment act?
Are your employees whom you plan to engage during implementation of activities for the
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Yes
Yes
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No
No
purposes of NIS j.s.c. Novi Sad trained to properly use, maintain and keep PPE?
Provide evidence/records about the existence of PPE Management System
3.10
Safe working methods
Yes
No
Does your Company have defined procedures/instructions in accordance with the requirements for safe
and environmentally-friendly work?
Work at height
Work in confined spaces
Work with hazardous materials (chemicals)
Isolation and locking of mechanical plants (including vehicles)
Hot works (welding etc.)
Lifting, moving and supporting of load
Driving and traffic management
Other – please explain
When you are working on power supply installations, does your company have safety
procedures/instructions for:
Gas facilities
Electric power
Water/Steam facilities
Flammable liquids
Provide evidence by enclosing copies of work procedures / Occupational Safety Guidelines
3.11
Risk identification and risk management
Does your Company have a system/procedure for identification and analysis of danger and
damage?
Does your Company have an established procedure for systematic identification and control
of significant risks during work activities? (e.g. the system of work permits)
Does your Company have Risk Assessment Act?
Does your Company have a system/procedure to ensure safety of anyone present at the
location of work execution or in its vicinity (e.g. third parties)?
Provide evidence by enclosing records/documents of the risk management system
Yes
No
3.12
Readiness for urgent/emergency situations and response to them
Yes
No
Does your Company have procedures to react in emergent situations at the relevant
workplace?
Will your Company have a person(s) certified in first aid/emergency response during the work
at the locations of NIS j.s.c.?
Provide evidence by enclosing records/documents /procedures of responding in emergency situations?
3.13
Environmental Protection (EP)
Does your company have an appointed person responsible for waste management?
Does your company keep records about quantities of generated waste on a daily and annually
basis?
Does your company have procedures for waste management and hazardous
materials/chemicals management?
Are your employees who work with hazardous waste and hazardous materials/chemicals
trained to work with these materials?
Provide evidence by enclosing records/documents for waste management and hazardous
materials/chemicals management
04. Other important information
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No
If you have any additional information which might help us assess your capacity, confirming that you are
working in accordance with the HSE and/or safely and environmentally-friendly, please enclose them too.
4.1
Other/Additional Documents
1.
2.
3.
4.
5. …
Provide evidence by enclosing records/documents
Yes
No
Occupational Safety and Health
Risk Assessment Act was passed ____.____._______. (specify the date in the format dd.mm.yyyy.)
Audit of Risk Assessment Act was conducted (planned for) ____.____.________. (dd.mm.yyyy.)
Authorized/designated person for OSH: ____________________________________________________
(specify the name, surname and UMCN of Person for OSH)
Possesses Certificate of Practical Capacity to perform Occupational Safety and Health activities
_______________________________
(certificate number, date of issue)
Specify members of the OSH Board (if any):__________________________________________
(specify name, surname and function)
_____________________________________
(specify name, surname and function)
_____________________________________
(specify name, surname and function)
_________________________________
(specify name, surname and function)
_________________________________
(specify name, surname and function)
05. Conditions
All Contractors, Subcontractors and their employees have to comply with HSE requirements of NIS j.s.c. Novi Sad:

HSE Policy;

Internal rules in the field of Occupational Safety and Health, Environmental Protection and
Fire Protection;

Adverse event management requirements in the field of Occupational Safety and Health,
Environmental Protection and Fire Protection;

Requirements of internal standards of NIS j.s.c. Novi Sad;

Rules for safe work in the field/location;

Specific rules and requirements regarding specific projects;

Requirements and sanctions defined by the primary HSE Annex.
As a representative of the _________________________________________________________________,
(full name of the company as recorded in the Decision issued by the Business Registers Agency)
I agree on behalf of the Contractor as well as on behalf of all employees of our Subcontractors that we will comply
with the requirements/recommendations issued by NIS j.s.c. Novi Sad. The Company NIS j.s.c. Novi Sad shall not
be responsible for incidents and accidents incurred during the Activities of Contractor/Subcontractor.
Signed on behalf of the Contractor:
Full name and surname of the Representative of Contractor: ________________________________
Signature: ___________________________________
Date: __.__._____. (dd/mm/yyyy)
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*Note: Fields shall be completed by Procurement Administrators and Person for IES and OSH, and/or responsible person in NIS j.s.c.
Novi Sad, in order to confirm completeness and validity of documents in terms of HSE.
Opinion on submitted documents of a potential Contractor *
Person for IES and OSH
_________________________________________
(position, name and surname –( written legibly in block letters), signature))
Notes*
Responsible person NIS j.s.c. Novi Sad
______________________________________
(position, name and surname –(written legibly in block letters), signature))
Responsible person NIS j.s.c.. Novi Sad
______________________________________
(position, name and surname –(written legibly in block letters), signature))
Served to:
1.
2.
3.
4.
Procurement Administrator
Contractor's Supervisor
Person for IES and OSH
Archives
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