Clarksons Group Subcontractor and Supplier Prequalification Questionnaire
THE CLARKSONS GROUP OF COMPANIES Including Clarkson Electrical Limited, Cowley Refrigeration Limited and Petroleum Solutions 2024 Limited
Clarksons Group company you are seeking qualification with
Clarkson Electrical Limited
Cowley Refrigeration Limited
Petroleum Solutions 2024 Limited
Section 1: General Information
Legal Company Name
*
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Email
example@example.com
Contact Phone Number
-
Area Code
Phone Number
NZ Business Number
GST Number
Years in Business
Number of Employees
Primary Industry/Scope of Work
Select what insurances you currently hold
Public Liability Insurance ($2 Million Dollars) - Required
Professional Indemnity Insurance
Motor Vehicle Insurance - Required
Contract Works
Other
Attach insurance certificates referencing the above answer.
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Public Liability Insurance, Professional Indemnity Insurance, Motor Vehicle Insurance, Contract Works and others.
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Event Reporting, Recording & Investigation
In the last 5 Years has your business been investigated or prosecuted by WorkSafe or any other legislative authority?
Yes
No
Does your company have a system in place for recording, reporting & investigating all accidents and near misses?
Yes
No
How many Lost Time Injuries has your company had over the last 5 years?
How many Medical Treatment Injuries has your company had over the last 5 years?
What was the date of your last MTI or LTI
-
Month
-
Day
Year
Date
Does your company have a Rehabilitation and Return to Work policy or process in place?
Yes
No
Health and Safety Management
Does your Organization have an Occupational Health and Safety Management System in place, and is it certified by a recognized certification body? If yes, please ensure you attach a copy of the certification below.
Yes
No
Is your Company certified with any of the following
Site Wise
Site Wise Gold
Impac Prequal
ISN
Totika
Avetta
Other
Does your Organization have a Quality Management System in place? If yes, please ensure you attach a copy of the certification below.
Yes
No
Will you be using subcontractors for the work you complete for us? If yes, please attach evidence of how you manage and review subcontractors below.
Yes
No
N/A
Do you maintain a hazardous substances/products register or inventory in relation to potentially hazardous products, materials and substances? If yes, please attach applicable SDS below.
Yes
No
N/A
Do you have a current hazard register? Please attach copy below.
Yes
No
Do you have a form or process to identify, control and record hazards? Please attach copy below.
Yes
No
Does your company provide PPE for its employees?
Yes
No
Do you carry out health monitoring for your workers?
Yes
No
Please confirm and attach the following policy statements.
Drug and Alcohol Policy
Environment Policy
Health and Safety Policy
HS&E Objectives
Other
Attach the below documentation.
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Health and Safety Management System, Quality Management system, Certifications if relevant, Subcontractor Management, Hazardous substance SDS's, Hazard register and associated forms, Policies
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Information, Training & Supervision
Do all employees hold relevant licences and/or qualifications of competency for the work conducted? This may also include years of experience.Evidence should include all health and safety based training, skills training, trade licences, trade qualifications, equipment and operator licences and years of experience.
Yes
No
Does your company provide training to ensure that all employees are competent to perform the work to be conducted?
Yes
No
Does your company have a training register? Please attach snippet
Yes
No
Does your company use Safe Work Method Statements (SWMS) and/or Job Safety Analysis (JSA's). Please attach example
Yes
No
What does your company do to manage higher risk or hazardous work? (Remote/ isolated tasks, atmospheres with potential for fire or explosion, notifiable works etc.) Please explain the process.
Attach evidence of training, SWMS, JSA and other requested documents
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Training matrix (preferred), employee inductions, trade licences, certificates/ qualifications etc.
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Employee Participation in Health & Safety Management
Does your company conduct safety toolbox talks with all field staff and does it get signed off by all attendees? Please attach an example.
Yes
No
Does your company have a H&S committee and hold regular meetings, with both management and employees represented? Is it recorded and circulated to staff?
Yes
No
Do your service vehicles have first aid kits and Fire Extinguishers supplied and a current test date?
Yes
No
Attach the requested documentation
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Toolbox Talk attendance sheet
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Terms and Conditions
Type a question
I confirm I read and understood Clarksons Terms for Suppliers and Subcontractors
Clarksons Group Terms and Conditions
Declaration and Submission
I, undersigned, declare that the information provided in this questionnaire and attached documents is accurate and truthful. I understand that any misrepresentation may lead to disqualification or termination of our business relationship
Full Name
First Name
Last Name
Position
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