1. Name of Organisation *

2. Address and postcode *

3. Name of key contact *

4. Key contact telephone number and email address *

5. Company website address *

6.VAT number *

7. Please provide bank details for payment – Name of account, sort code, account number *

8. Have you ever traded under another name? *
YesNo

9.If yes, please provide names and dates

10. Is each member of your organisation aware of their responsibilities under the Construction Design and Management Regulations 2015?
YesNo

11. If no, please provide details

12. Please provide information on all prohibition, improvement or other enforcement notices issued against your company within the past five years *

13. Please provide number of fatalities/major accidents over the last four years *

14. Please provide total of RIDDOR Reportable Accidents/Incidents over the last four years *

15. Please provide number of near misses over the last four years *

16. Please provide number of prosecutions over the last four years *

17. Please provide the number of improvement notices served on your company in the last four years *

18. Please provide the number of prohibition notices served on your company in the last four years *

19. Please provide the number of environmental incidents in the last four years *

20. Please provide details of any prosecution against your company, or individuals employed by your company, for breaches of health and safety legislation within the past five years *

21. Please confirm the past 3 years’ health and safety training within your organisation, including asbestos *

22. Outline your organisational procedures for disseminating up to date developments on health and safety issues*

23. Please provide the names and qualifications of internal safety advisers and/or external safety consultants, including specialist resources, used by your organisation *

24. Are there safety representatives appointed within your workforce? *
YesNo

25. Do you have a safety committee for consultation purposes? *
YesNo

26. Do you currently undertake risk assessments/method statements as part of your duties under the management of health and safety at work regulations? *
YesNo

27. Does your organisation currently undertake a post-contract reviews of health and safety management? *
YesNo

28. Outline your organisation structure, for the co-ordination of health and safety information between yourselves and the principal contractor *

29. How do you ensure sub-contractors are competent? *

30. Can you confirm that all relevant method statements and risk assessments will be presented for review prior to commencement of any works on site? *
YesNo

31. Please provide the name and position of the person completing this form *

32. Please upload the following documents:

• Up to date insurance certifications (PLI/ELI)

• Current H&S policy statement

• An outline of your management structure regarding H&S responsibilities together with the name of the most senior Director responsible for safety and the signatory on your H&S policy

• At least 3 sample risk assessments