Contractor Safety Assessment Form

(To be completed and issued once throughout the duration of the contract. Submit duplicate copy to MNTPLN)

Assessor:

Date:

General Information
1. Contractor Company or Name:
2. Mailing Address:
3. Telephone Number:
4. E-mail Address:
5. Contractor companys contact person:
Work Details
1. No of contractors on site:
2. Work to be done:

3. Duration of contract: Start date;

4. List of equipment and major work tools:

End date;

Safety Documents Verification

1.
2.
3.
4.
5.
6.
7.
8.

(Yes=, No=X)

Signed copy of Contractor Work permit Document(s)

Signed copy of Risk Assessment Document
Signed copy of gas-work application form (If applicable)
Copies of maintenance history of each equipment to be used
Signed copies of certification of each equipment by reputable third party
Copies of certificates of conformance for lifting gears (If applicable)
Copies of certificates of conformance for lifting gears (If applicable)
Copies of documents licensing contractors to perform special jobs

Equipment and Tools Health Check

1. Equipment in good condition according to APMT GMR standards
2. Work tools in good condition according to APMT GMR standards

Approval
Yes

No

Conditional

Additional Comments

APMT Assesors Signature

APMT Job Owner Signature