Blank (PEREZ-CSHP) CSHP-form-revised-2023-AO-APR-11
Blank (PEREZ-CSHP) CSHP-form-revised-2023-AO-APR-11
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.
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.
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.
B. Project Profile/Description
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the
project)
Email :
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.
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:
Submitted By: