Scribd
Upload
34 views

Comprehensive CSHP Application Form

This document is an application form for approval of a Construction Safety and Health Program (CSHP) for a specific construction project. It requires information about the main contractor's profile, license, registration and workforce. It also requires a project profile including the name, location, owner, classification, estimated workers, costs and description of activities. Additionally, it requests information on assigned OSH personnel like safety officers and first aiders, their training dates and certificates. For projects with over 50 workers or heavy equipment usage, additional OSH roles are required. The applicant certifies the truthfulness of the information and commitment to implement the attached CSHP.

Uploaded by

jazzygameseu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
34 views

Comprehensive CSHP Application Form

This document is an application form for approval of a Construction Safety and Health Program (CSHP) for a specific construction project. It requires information about the main contractor's profile, license, registration and workforce. It also requires a project profile including the name, location, owner, classification, estimated workers, costs and description of activities. Additionally, it requests information on assigned OSH personnel like safety officers and first aiders, their training dates and certificates. For projects with over 50 workers or heavy equipment usage, additional OSH roles are required. The applicant certifies the truthfulness of the information and commitment to implement the attached CSHP.

Uploaded by

jazzygameseu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

Form Reference No: PM-NCR-03.

08-F-04

NO FEES REQUIRED FOR THE FILING , EVALAUTION AND APPROVAL OF CSHP


Revised Form.: CSHP-DO13-98:
Date of Revision : June1, 2011 Page 1of 3

REVISED APPLICATION FORM for


Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

Legal Basis: Section 5 of Department Order No. 13 s 1998


(Guidelines Governing Occupational Safety and Health In Construction Industry)

Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR in applying for an approval of a Construction Safety and Health Program intended for
a specific construction project.

Note: A CHECKLIST OF REQUIREMENTS shall be used in receiving the application.

Only an application form with a complete requirements and attachments will be processed.
Application found with incomplete requirements will be given 15 calendar days to comply. Failure to
comply within the prescribed period, the application will be deemed disapproved.

A. Company Profile/License/Registration of Main/General Contractor


Complete Name of the Company/ Complete Address:
Main /General Contractor 85 Purok 5 Juliana Subdivision, City of San Fernando, (P)
Tel. No:
Admin
Fax No.
Name of Project Manager/Contact Person: Email:

Harold E. Manabat ar.harold.manabat@gmail.com

Main Contractor PCAB License Main Contractor Total employment _______


No.______________ ___ Male _____ Female _____

Date of Validity:_______________________
DOLE Registration of Main Contractor (Pls. attach photo copy of Registration forms received and approved by the
concerned DOLE Regional Office)
Date Registered/Approved DOLE-RO
a. per DO 18-02 (requires yearly renewal) ___________________ __________

b. per Rule 1020, OSHS (one time registration) __________________ ___________


Sub-contractors’ Profile/License
No. of PCAB Validity Date of
Name of Sub-contractors (If , any) Scope of Work and Workers License Date DOLE
Project Cost Registration
1.

2.

3.

4.

5.

(Use separate sheet , if necessary)


REVISED APPLICATION FORM for
Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

B. Project Profile/Description
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the
project)

Proposed 2-Storey Residence

Complete Project Address/Location

Lot 2, Blk 48 Essel Park, Brgy. Telabastagan, City of San Fernando, Pampanga

Name of Project Owner


Tel. No: _____________

Peter Jordan S. Pelayo Fax No: _____________

Email : _____________

Project Classification: Date of Estimated Start/Execution of


Estimated No. of Workers to the project:
be deployed in the project: __January 30, 2020 __
Month Day Year
______12_____________
Duration of the project (Pls.
Total Project Cost: PHP 3,133,846.25 . (Workforce of the project to state the number of calendar days
include workers of the sub-
contractor/s) ________185_________________

Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)

Revised Form.: CSHP-DO 13-98


Date of Revision: June1, 2011 Page 2of 3
Department of labor and Employment APPLICATION FORM for APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY AND HEALTH PROGRAM

OSH Personnel assigned to the project

Name of Appointed Safety Officer/s: Name of Appointed First-Aider/s:

_________Renell Martin G. Nuqui . _ Kenneth Rj D. Santelices

Date of his/her BOSH training: Ocrober 5-6 & 12-13, 2019 Date of First –Aid Training: October 11-12, 2018

(Pls. attach photo copy of Certificate of Completion on the Basic Validity of ID: __________________
OSH Course for Construction Site Safety Officers issued by
DOLE-BWC accredited Safety Training Organizations or (Pls. attach photo copy of Certificate of First-Aid Training
recognized institutions) and Valid First Aider ID from PNRC

Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of 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 (To attach photo
(Please attach additional sheet, if necessary) copy of skills certification from TESDA)

Profile of the person who prepared the CSH Program for the abovementioned Project:
Name and Signature Educational Background:

___________________________ Work Experience in OSH:


Signature over printed name
Other Qualifications:

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULLNESS OF THE ABOVEMENTIONED


INFORMATION. THE COMPANY HEREBY COMMIT TO STRICTLY IMPLEMENT THE ATTACHED
CONSTRUCTION SAFETY and HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.

Submitted By:

Signature Over Printed Name ______________________________________

Position: ______________________________________________________

Date: ______________________________________________________

Revised Form.: CSHP-DO 13-98


Date of Revision: June1, 2011 Page 3 of 3

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy