Cargill – Environmental, Health & Safety

IDANZ/EHS/Project/CSMS/Form/001

EHS Contractor Pre-Questionnaire

Issued date: July 20th, 2020 Revision date: July 20th, 2020 Revision no: 01

EHS Contractor Pre-Questionnaire Form

Questionnaire items Evidences

Availability (Y/N)
Please attached

Section 1: Leadership and commitment

1.1 a) How are senior managers personally involved in EHS management for example Attach EHS
objective-setting and monitoring? Commitment
Commitment to EHS
aspects through b) Provide evidence of commitment at all levels of the organization? attached
Leadership By meeting,
(MANDATORY QUESTIONAIRES) c) How do you promote a positive culture towards EHS matters?
champion program

Section 2: EHS policy and strategic objectives

2.1 a) Does your company have an EHS policy Attach EHS Policy
EHS Policy documents document? If the answer is YES please
attach a copy. Doffy syam
(MANDATORY QUESTIONAIRES) b) Who has overall and final responsibility for EHS in your organization?
c) Who is the most senior person in the organization responsible for this policy Iqbal s
being carried out at the premises and on site where his employees are (direkrut)
working? Provide name and title.
d) Itemize the methods by which you have drawn your policy statements to the Safety meeting
attention of all your employees?
e) What are your arrangements for advising employees of changes in the By meeting &
policy? emailing

2.2 a) Does your company have strategic EHS objectives? If the answer is YES please Attach EHS Target &
attach a copy. Program
EHS contract strategic
objectives By safety meeting
b) Itemize the methods by which you have communicated your strategic EHS
objectives to the attention of all your employees?

Section 3: Organization, responsibilities, resources, standards and documentation

3.1 a) How is your organization structured to manage and communicate EHS Attach Org.
effectively? structure/chart
Organizational
(Incl. EHS)
structure for EHS yes
b) Do EHS meetings promote EHS awareness?
management
c) Do client and contractor/subcontractor meet regularly to discuss and yes
action any interface situations?
d) What provision does your company make for EHS communication attached
meetings? Please provide an organization chart
3.2 a) Have the managers and supervisors at all levels who will plan, monitor, Attach EHS Training
oversee and carry out the work received formal EHS training in their matrix & Record
EHS training of managers,
supervisors and EHS responsibilities with respect to conducting work to EHS requirements?
critical position holders b) If YES please give details. Where the training is given in-house please describe
the content and duration of courses. Please provide an example of training
matrix. Using HIRAC & JSA
c) How have you identified areas of your company’s operations where specialized
training is required, for instance training related to health hazard such as
radiation, asbestos and chemicals?
d) What specialist EHS resources does your organization have available? Attach EHS training
for EHS person
e) How does your company provide EHS specialized training for EHS staff?
 Cargill – Environmental, Health & Safety
IDANZ/EHS/Project/CSMS/Form/001

EHS Contractor Pre-Questionnaire

Issued date: July 20th, 2020 Revision date: July 20th, 2020 Revision no: 01

3.3 a) What arrangements does your company have to ensure new employees have Attach induction
knowledge of basic industrial EHS, and to keep this knowledge up to date? training material
General EHS training
b) What arrangements does your company have to ensure new employees also Hold Refreshing EHS
have knowledge of your EHS policies, practices and company requirements? Training

c) What arrangements does your company have to ensure new employees have Orientation &
been instructed and have received information on any specific hazards arising induction
out of the nature of the activities?
NB for (a), (b) & (c): if training is provided in-house, please give details of content
3.4 a) Does your organization have a competence system in place? Attach EHS
If YES, please describe the scope and content of your competence system. competency list of
Competence
EHS person and
assurance b) What arrangements does your company have to ensure existing staff EHS skilled person
knowledge is up to date?
3.5 a) Does your company have a contractor/subcontractor management process or Attach procedure of
system? If yes, provide an outline of the process. contractor/
Contractor management
subcontractor
process b) How do you assess contractors/subcontractor, EHS competence or EHS selection process
performance?
c) Where do you define the company standards you require your contractors to meet? (CSMS procedure)

d) How do you ensure these standards are met and verified?

3.6 a) How do you identify new industry or regulatory standards that may be applicable Attach EHS
to your activities? Regulatory
EHS standards
compliance and list
b) Is there an overall structure for producing, updating and disseminating of EHS standard you
standards? are using
c) Are your company standards aligned with industry guidelines or recommended
practices? If yes state which one.

Section 4: Risk management

4.1 a) How does your company identify hazards, assess risk, control and mitigation Attach EHS Risk
consequences, to a level as low as reasonably practicable? Assessment
Risk assessment and control
(MANDATORY QUESTIONAIRES)

4.2 a) Do you have specific policies and program on specific health hazards e.g. yes
Health hazards substance abuse, blood borne pathogens, malaria pandemic diseases etc.
b) What type of health hazards (chemical, vibration, noise, radiation, etc.) By JSA
are associated with the scope of your services? Explain how occupational
health hazards are identified, assessed and controlled.
c) What systems are in place to control these hazards and monitor the effectiveness Administrative
of these controls? Is worker’s regular exposure monitoring part of these & PPE
systems? All of
4.3 a) What type of safety hazards (mechanical guarding, work at height, lifting and
Safety hazards hoisting, confined space entry, explosive atmospheres etc.) are associated with mentioned
the scope of your services?
b) What systems are in place to control these hazards and monitor the effectiveness By Permit to
of these controls? work
4.4 a) What type of logistics hazards (land transport, air transport, marine transport, land
Logistics hazards materials handling etc.)are associated with the scope of your services?
b) What systems are in place to control these hazards and monitor the effectiveness JSA
of these controls?
4.5 a) What type of environmental hazards (chemical spill, atmospheric emissions, waste Chemical spill
Environmental hazards disposal etc.) are associated with the scope of your services?
b) What systems are in place to control these hazards and monitor the effectiveness Permit work &
of these controls? JSA
 Cargill – Environmental, Health & Safety
IDANZ/EHS/Project/CSMS/Form/001

EHS Contractor Pre-Questionnaire

Issued date: July 20th, 2020 Revision date: July 20th, 2020 Revision no: 01

4.6 a) What type of security hazards (terrorism, hostage taking, robbery, hostile local Robbery
Security hazards population etc.) are associated with the scope of your services?
b) What systems are in place to control these hazards and monitor the effectiveness Security department
of these controls?
4.7 a) What type of social hazards are associated with the scope of your services? demonstration
Social responsibility b) What systems are in place to control these hazards and impacts and monitor the CSR, Permit building
hazards effectiveness of these controls?
4.8 a) What systems are in place in your Company to procure and providence of personal Attach PPE matrix
Personal Protective protective equipment and protective cloth for daily activities and for specific
Equipment working activities ?

b) Does your company provide personal protective equipment (PPE) which is suitable yees
to your employee working condition?
Please provide list of PPE required to perform the job.

c) Does your company provide training about how to correctly use PPE? Please Attach PPE training
provide evidence of slide presentation and follow up after the training material & training
records

d) Does your company has in place program to ensure that PPEs are inspected and Attach PPE
maintained? inspection program

Section 5: Planning and procedures

5.1 a) Do you have a company EHS-MS manual (or operations manual with Attach EHS Manual,
integrated EHS requirements) which describes in detail your company SOP, method
EHS operations
approved EHS working practices relating to your work activities? statement for
manual
critical work
(MANDATORY If the answer is YES please attach a copy of an index and relevant supporting
QUESTIONAIRES) documentation.
b) How do you ensure that all method statement and working procedure used
by workers are consistent to the implementation of EHS Policy vision?

5.2 a) How do you ensure that infrastructure, plant and equipment used within your Attach list of
operations (own premises, client site, or at other locations) are correctly equipment,
Infrastructure and
certified, registered, controlled and maintained in a safe working condition? equipment
equipment integrity
inspection program
5.3 a) How do you manage changes and assess associated risks e.g. personnel, Attach MOC
equipment, processes, documentation? procedure
Management of change
5.4 a) What arrangements does your company have for emergency planning Attach Emergency
and response? Response Plan
Emergency planning and
response b) Which emergency situations are included?

Section 6: EHS Implementation and performance monitoring

6.1 a) What arrangements does your organization have for monitoring the Attach EHS
implementation of your EHS-MS? monitoring & report
EHS-MS
implementation and active b) How does your company assure the implementation of work procedures within By Safety report &
performance monitoring of your work-site operations e.g. compliance with procedures, toolbox talks, management visit
work activities safety meetings, supervision, job observations?
c) How do you monitor employee EHS performance e.g. hazard identification Take regular quiz &
systems, EHS participation? refreshing EHS

d) What active EHS monitoring is performed (i.e. where no incident has Attach file EHS
occurred)? findings & action
log/register
e) How do you report and correct deficiencies identified?
 Cargill – Environmental, Health & Safety
IDANZ/EHS/Project/CSMS/Form/001

EHS Contractor Pre-Questionnaire

Issued date: July 20th, 2020 Revision date: July 20th, 2020 Revision no: 01

f) How do you communicate the results of active performance monitoring to

relevant personnel?
6.2 a) Please provide the following statistics for each year for the last five years: Attach lagging &
leading indicators
Safety performance • Number of fatalities
for the last five (5)
indicators • Number Lost Time Injuries years
• Number of Lost Workday Cases
• Number of Restricted Work Day Cases
• Number of Medical Treatment Cases
• Number of first aid cases
• Number of near miss incidents
• Fatal Accident Rate (per 100 million hours worked)
• Lost Time Injury Frequency (per million hours worked)
• Total Recordable Incident Rate (per million hours worked)
• Other specific EHS KPI as per scope of work.
Please provide term and definition of your company in separate page.

6.3 a) How is health performance monitored and recorded? Annual MCU

EHS performance b) How is environmental performance monitored and recorded? EHS report monthly
monitoring
c) How is security performance monitored and recorded? EHS report monthly

d) How and what near miss incidents are reported? EHS report monthly

e) How often is EHS performance reviewed? By whom? Annualy by audit

team
f) How is logistics performance monitored and reported? Warehouse report

g) Do you record vehicle incidents? yes

6.4 a) What types of EHS incident are investigated? Attach incident

EHS incident investigation investigation
b) What process is used to investigate EHS incidents? procedure and
and follow up
sample of
c) Who conducts EHS incident investigations?
investigation
d) How are the findings of an incident investigation followed up to ensure
effective prevention of recurrence?

e) How is incident learning communicated to all relevant personnel?

6.5 a) Has your company suffered any statutory notifiable incidents in the last five years no
Statutory notifiable (safety, occupational health and environmental)?
incidents or Non Answers with details including dates, country and location, summary of
compliance notices incident and follow-up preventative measures taken.

Section 7: EHS auditing and management review of EHS-MS

7.1 a) Do you have a written procedure for EHS auditing? If yes, please attach a Attach procedure of
copy. EHS Audit & Sample
Audits
of Audit report
b) Who is involved in conducting EHS audits? How are audit team members
selected to have specific expertise and be independent from the activities
being audited? What are the qualifications required for auditors?
c) How does your company schedule EHS audit and what scope of auditing is
covered? e.g. internal, regulatory compliance, supplier/contractor, EHS
management system implementation.
d) How does management follow up on audit findings and ensure effective close
out of action items?
 Cargill – Environmental, Health & Safety
IDANZ/EHS/Project/CSMS/Form/001

EHS Contractor Pre-Questionnaire

Issued date: July 20th, 2020 Revision date: July 20th, 2020 Revision no: 01

7.2 a) Do you have a written procedure for management review of the Attach procedure of
EHS-MS? If yes, please attach a copy Management
Management review and
Review & Sample of
follow up b) How often are EHS-MS reviews conducted and who is involved in the process? Report
c) How are identified actions and improvement efforts recorded and tracked to
effective completion?

Section 8: EHS management – additional features

8.1 Please provide information on any certification which you have received from Attach any EHS
certification bodies certification
Certification of your EHS-
MS
8.2 Describe the nature and extent of your company’s participation in relevant Not available
Memberships of industry, trade, and governmental organizations
associations
8.3 Does your organization (globally, regionally or locally) have any EHS features or no
Additional features of your arrangements not described elsewhere in your response to the questionnaire?
EHS-MS

Section 9 – Company specific information

This section is not scored.
The company can request any specific information that may be required to evaluate the contractor.

Section 10 – Leadership Commitment

I am committed to complete this project with zero injury and zero property damage. In achieving these goal, I am committed to comply with all
Cargill safety requirements, procedures, guidelines and applicable government regulations.

I have read and well understood Cargill Contractor Global EHS Requirements and I am committed to comply all applicable EHS requirements and
will comply if any new/change on the Cargill EHS Requirements during execution of the project.

NO Contractor Name Position Sign

1 Iqbal Safirul barqi Director

2 Slamet Sugiarto Project Manager

3 Eko prasetyo Wahyudi Asisten Project Manager

4 Doffy Syam Yulianto EHS Manager

Note : A Site visit is required to contractor office and work site to verify the Pre-Qualification questionnaire and supporting document submitted by
the contractor
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