Wood (AFW) Document No.

: 1000-310-0000-FRM-002
Contract No:14021000 Revision: R3

Brunei Shell Petroleum Document No.:

NOT APPLICABLE

Contract Title

Brunei Shell Petroleum

Facilities Rejuvenation Contract

Document Title

CONSTRUCTION and ENGINEERING CONTRACTOR

PREQUALIFICATION QUESTIONNAIRE
(HEALTH SAFETY SECURITY ENVIRONMENT)

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Wood (AFW) Document No.: 1000-310-0000-FRM-002
Contract No:14021000 Revision: R3

Brunei Shell Petroleum Document No.:

NOT APPLICABLE

1. Workers Compensation Insurance

Are you insured for Worker’s Compensation Insurance? YES NO

Have you lodged any claims against your Workers Compensation in the last 5 years? YES NO
(You will be required to provide supporting letter from the Insurer if selected to Tender)

Provide details of the nature that required a Workers Compensation Insurance claim:

2. HSSE Performance Statistics: The Tenderer shall provide statistical details listed below for the last three (3) years and current year to date.

YEAR Total Lost Time Total Lost Work Days Total Recordable Lost Time Incident Total Recordable Total Environmental
Incidents Incidents Rate Incident Rate Incidents
(Note any fatalities
Current YTD
(2017)
Previous Year
(2016)
Previous Year
(2015)
Previous Year
(2014)
Total Lost Time Incidents: Those work-related injuries or illnesses that result in a fatality, permanent disability or time lost from work of one day/shift or
more. Please note the number of fatalities in each year.

SF 1000-310-0000-FRM-002_Prequalification HSSE questionaire_R.3 Page 2 of 3

Wood (AFW) Document No.: 1000-310-0000-FRM-002
Contract No:14021000 Revision: R3

Brunei Shell Petroleum Document No.:

NOT APPLICABLE

2. HSSE Performance Statistics: The Tenderer shall provide statistical details listed below for the last three (3) years and current year to date.
Total Lost Work Days Total amount of days lost as a result of work-related injuries or illnesses.

Total Recordable Incidents Those work-related injuries or illnesses that resulted in Lost time or required Medical Treatment or Restricted Duties.
Please note the number of injuries and illnesses in each year.

Lost Time Incident Rate (LTIR) Formula: Formula calculated by the number of Lost Time Incidents, divided by toal exposure hours No. of LTI’s x 1,000,000
worked and multiplied by 1,000,000 Total Hours

Total Recordable Incident Rate (TRIR) Formula calculated by the number of Total Recordable Incidents, divided by total exposure No. of TRI’s x 1,000,000
Formula: hours worked and multiplied by 1,000,000 Total Hours

3. Risk Assessment
How does your company manage actions and mitigation plans
identified in the risk management process?
4. Training & Competency Program
Describe how training and competency needs are identified, met and
demonstrated.
5. HSSE Professional Management
Name of person in the company that is responsible for your Work
Health and Safety (WHS) management
List this person’s WHS highest qualification.

SF 1000-310-0000-FRM-002_Prequalification HSSE questionaire_R.3 Page 3 of 3