Document No. Revision No.

6
APO CEMENT CORPORATION IMS-PRC-002 Issue No.
TINA-AN, NAGA, CEBU, PHILIPPINES
1
TITLE Effective Date

Suppliers _Health and Environmental Questionnaire July 15, 2014 Page No.: 1 of 2

SECTION A : BASIC INFORMATION

Company Name :

Company Address :

Company Tel. & Fax No. /Emergency Number :

(Whom to Contact in case an emergency occur
Involving contractors Personnel

Nature of Business :

What kind of product(s) or service(s) do you supply to us?/

Please attach additional sheets if required. :

SECTION B : HEALTH AND SAFETY INFORMATION Perfect

Score: 290 pts.
Suppliers/
Service Evaluator’s
CRITERIA Yes/No
Contractors Rating
Rating
1. Does the contractor company have a Health and Safety Policy
documents? (e.g. identifying managers responsible for health
and safety and arrangements for carrying out the Policy.
2. Do they have Health and Safety Management Systems or you
have knowledge of such systems? (e.g. H & S Inspection, etc..)
3. Do they conduct relevant Risk Assessment /Method
Statements/Safe Systems of Work before every work?
4. Are their Safety in Charge knowledgeable on this?
5. Do they have Insurance Documentation (e.g. All Risk) before
work is being done?
6. Do they have details of Training received by your Personnel?
(e.g. subjects, frequency, training provider, etc..)
7. Are their Safety In Charge have undergone Basic
Occupational Health and Safety Training (BOHS)?
8. Are their employees undergone Training Certification like
welding, scaffolding, rigging, pipe fitting (and others) from
TESDA or reputable training organization or Certified
Experienced of his/her skills with good records?
9. Do they participate in relevant health and safety passport
schemes (if such schemes exist)?
10. Did they track the training of your people?
11. Do they have membership of trade organizations?
12. Do they have references to Certify your Health and Safety
Competence?
13. Do they have any Social Security Proof of Compliance?
(e.g. Proof of Payment for your employees working in the Plant
Sites is required).
14. Are they Compliant to the Occupational Health and Safety
Standards and the Mines Safety Regulations of DENR/MGB?
 Document No. Revision No.
6
APO CEMENT CORPORATION IMS-PRC-002 Issue No.
TINA-AN, NAGA, CEBU, PHILIPPINES
1
TITLE Effective Date

Suppliers _Health and Environmental Questionnaire July 15, 2014 Page No.: 2 of 2

SECTION C : ENVIRONMENTAL INFORMATION Perfect Score: 290 pts.

Suppliers/
Service Evaluator’s
CRITERIA Yes/No
Contractors Rating
Rating
1) Do you maintain an environmental permit? Please specify.
2) Have you determined the environmental impacts (effects) of the
product(s) or service(s) you are supplying and are proposing to supply to
us? Name at least ten (10) effects.
3) Do you have an Environmental policy?
4) Do you have a documented Environmental Management System?
If yes, which standard was it based from? If no, do you have plans of
establishing an Environmental Management System?
5) Do you have a Plant Emergency Organization?
6) Are you willing to have you compound audited by us environmentally? If
no, why?
7) Have your company been penalized or issued a notice of violation for
activities, products or services you have produced or rendered?
8) Do you know the ISO 14000 series of standards?
9) Do you know the British Standard (BS) 7750?
10) Do you know the Environmental Management Audit Scheme (EMAS)?
11) Do you recycle your wastes and re-use them in your products or
rendering your services?
12) Do you have a Waste Management Program being enforced in your
company?
13) Do you conduct tree-planting programs in your area or outside your area?
14) Do you monitor your electric power consumption and follow energy
conservation programs?
15) Do you monitor your water consumption and follow water conservation
programs?

TOTAL SCORE : _____________(_______)

Note:
Rating Scheme: No: 0 pt., Yes: 10 pts., If at planning stage:5 pts.; except criteria #7.
If your answer is yes, and it requires long explanation, supporting data, important information and documents, kindly
have it on attachment sheets.

Checked by: _______________ Audited by: ________________ Noted by: ________________________

Buyer Deputy _MR Procurement & Warehouse
Manager