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Blank (PEREZ-CSHP) CSHP-form-revised-2023-AO-APR-11

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0% found this document useful (0 votes)
27 views4 pages

Blank (PEREZ-CSHP) CSHP-form-revised-2023-AO-APR-11

Uploaded by

SafetyAerod
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NO FEES REQUIRED FOR THE FILING, EVALUATION AND APPROVAL OF CSHP

Revised Form.: CSHP-_________


Date of Revision: April 5, 2023 Page 1of 3

REVISED APPLICATION FORM for


Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. 03 CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

Legal Basis: 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 complete requirements and attachments will be processed. Applications 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
Tel. No:
N/A
Fax No.
Name of Project Manager/Contact Person: Email:
MARIE PAIGE SEVEN BAUTISTA paigeseven@studio-higala.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 174-17 ( 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. 03 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)

TWO (2) STOREY 8-UNIT APARTMENT

Complete Project Address/Location of the Project:

Lot 1764-B, Tabtab St., Brgy. Poblacion, Norzagaray, Bulacan

Name of Project Owner:


Tel. No:
MS. SHERINE PEREZ & MS. SHERYLINE PEREZ Fax No:

Email :

Project Classification: Date of Estimated Start/Execution of


Estimated No. of Workers to the project:
be deployed in the project:
Month Day Year

Total Project Cost: (Workforce of the project to Duration: _______ calendar days
include workers of the sub- (Pls. state the number of
contractor/s) calendar days)
Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)
3.

Department of labor and Employment APPLICATION FORM for APPROVAL OF


REGIONAL OFFICE NO. 03
CONSTRUCTION SAFETY AND HEALTH
PROGRAM
OSH Personnel assigned to the project

Name of Appointed Safety Officer/s:


Name of Appointed First-Aider/s: _________________
1. 1. ___________________________________________ 1. _______________________________________ 1. 1.

Date of his/her COSH training: ____________________ Date of training: _____________________


Validity of ID:
2. ___________________________________________
2.__________________________________________
Date of his/her COSH training: _____________________ 1. 1.

Date of training: ___________________


3. ___________________________________________
Validity of ID:
Date of his/her COSH training: _____________________
3.__________________________________________
4. ___________________________________________ 1. 1.

Date of training: ___________________


Date of his/her COSH training: _____________________ Validity of ID:
(Pls. attach photocopy of Certificate of Completion on the Basic
OSH Course for Construction Site Safety Officers issued by (Pls. attach a photocopy of the Certificate of First-Aid Training
and Valid First Aider ID from Phil Red Cross, DOH, Bureau of
DOLE-BWC accredited Safety Training Organizations or Fire and DOLE- Accredited TVIs with TESDA registered EMS
recognized institutions) and other DOLE-Accredited first aid training provider)

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 Name of Heavy Equipment Operator/s (To attach
Project (Please attach additional sheet, if photocopy of skills certification from TESDA)
necessary)

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


EVALUATOR
I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE

Signature Over Printed Name Position Date


BASED ON THE DOLE PRESCRIBED CHECKLIST.

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