DEPARTMENT OF LABOR AND EMPLOYMENT FM-DOLERO3-TSSD1-CSHP-01

Regional Office No. III Effectivity: August 15, 2013

City of San Fernando, Pampanga

PROJECT TITLE:

CONTRACTOR:

CHECKLIST FOR EVALUATION OF CONSTRUCTION SAFETY AND HEALTH PROGRAM

per requirements of D.O. No. 13 series of 1998

YES REMARKS YES REMARKS

A. GENERAL REQUIREMENTS
1. Two (2) copies of letter of Intent (optional) d. Formworks/Scaffoldings
2. Two (2) duly accomplished application form e. Temporary electrical connections/
3. Two (2) copies of the Safety and Health Program. One copy installations
must be original print. f. Structural Steel
B. CONSTRUCTION SAFETY & HEALTH PROGRAM MUST g. Concrete works

CONTAIN THE FOLLOWING: h. Gas and electric welding and cutting

1. Name of person who prepared the program: (please indicate operations
if accredited by DOLE as OSH Practitioner) i. HVAC
2. Name of person who approved the program: j. Piling
(Project Owner/General Manager/Contractor) k. Plumbing Works.
3. General Safety & Health Policy written on a company letter l. Roofing Works
head. Must be duly signed by the highest company official or m. Use of power tools and equipment
the highest ranking company representative who has over all n. Working in confined spaces
control of project execution. o. Use of Internal Combustion engines

4. Composition of Safety and Health Committee (per project) p. Use of hand tools
Must specify the proposed structure and membership of the q. Use of mechanized lifting appliances for
movement of materials
safety and health committee (specify names)
r. Use of construction heavy equipment
Chairman - Project Manager/Project-in-Charge
s. Installation, use and dismantling of
Secretary - Safety Officer
hoist and elevators.
Members - Health Personnel and Workers (Depending on
20. Company Rules and Regulations in
the no. of workers deployed at the
Implementing of Safety and Health
construction site)
21. Penalties/Sanctions for violation of the
provision/s committed by workers
5. Specific duties and responsibilities of the Chairman, Safety
C. ATTACHMENTS
Officer, Health Personnel and Members of the S&H Committee
1. Photocopy of the Registration Forms
received and approved by the
SPECIFIC PROVISIONS ON THE FOLLOWING (if applicable)
concerned DOLE Regional Office
6. On-site safety and health promotions and continuing -per D.O.18-A (for Sub-Contractor/s)
Information-dissemination -per Rule 1020 of the OSHS
7. Accidents and Incident Investigation and reporting 2. PCAB-DTI License
8. Protection of the general public within the vicinity of the 3. Photocopy of Invitations to Bid/
construction site Project Contract/ Program of works
9. Environmental Control 4. Photocopy of Certificate of Completion
10. Personal Protective Equipment (Indicate the provision of required Training of all designated OSH
PPE at contractor's own expense) Personnel
11. Handling of Hazardous susbtances Safety Officer-Basic Occupational Safety
12. General Materials handling and storage procedures and Health Training for Construction Site
13. Temporary Fire Protection Facilities and equipment OH Nurse-Basic Occupational Safet and
14. First Aid and health care medicines, equipment and Health Training for OH Nurse (if any)
facilities (Including transportation facilities in case of First Aider-Standard First Aid Training and
emergency) Valid PNRC ID as First Aider
15. Workers Welfare Facilities (source of drinking water, OH Physician-Basic Course on Occupational
restroom, place to take meal, wash area barracks (for house in Medicine (If any)
workers)) 5. Certificate of Inspection and Testing of
16. Proposed Hours of Work and Rest Breaks (8hrs a day) Construction Heavy Equipment (CHE)
17. Construction waste disposal conducted by a DOLE accredited Inpection
18. Disaster and Emergency Preparedness contingency plan and Testing Organization
19. Standard Operating/Safety Procedure and Job Hazard
6. Skills Certificate of Construction Heavy Equipment
Analysis for the following activities and other hazardous work
Operators Issued by TESDA(if any)
not outlines herein (This is based on Scope of Works)
a. Site Clearing 7. Skilled Workers Certification issued by TESDA
b. Excavations 8. Contract with nearby hospital/clinic in lieu of the
c. Demolition required Infimary hospital (If Any)

Note:

RECOMMENDATION:
Evaluated by: ___________________________ Date: _____________________ FOR APPROVAL
FOR COMPLIANCE OF LACKING DOCS.
FOR DISAPPROVAL
Noted by: ARLENE N. TOLENTINO Date: _____________________
PFO HEAD - PAMPANGA

Reviewed by: ________________________________ Date: _____________________