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CONTRACTOR'S HSE QUESTIONNAIRE Doc. Number: WSI/HSE/FORM-03

PT. WAHANA SAFETY INDONESIA

27 INCIDENT INVESTIGATIONS
a) Do you have a procedure for the investigation, reporting and follow up of accidents, dangerous, occurences or occupational illness

b) Are the result of accident investigations communicated to the employees? (please give examples)

28 HAZARD IDENTIFICATION AND RISK ASSESSMENT

a) Do you have hazard identification and risk assessment for product, activities etc; if yes, please attached

28 OTHERS
a) Do your employees read, write, and understand English such that they can perform their job tasks safely without and interpreter? If no,
provide a description of your plan to assure that they can safely perform their jobs

b) Please provide the details of any significant safety achievements or awards

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CONTRACTOR HSE EVALUATION CRITERIA Doc. Number: Doc. Number: KAS-HSE-FORM-03

A B
1 POLICY STATEMENT No written Safety Policy A policy statement exists
but not in a widely
distributed document
C D
Safety Policy Policy clearly establishes responsibility and
Established accountability and is distributed to all employees
responsibility for safety but with periodic updates
not widely distributed

2 EMERGENCY No written Emergency Basic Procedure Only Emergency Procedures
RESPONSE Response written for major scenarios,
e.g. fires/explosion, release of
toxic or flammable materials
and medical emergencies. No
requirements established for
drill frequencies
Emergency procedures for all majors scenarios,
e.g. fire/explosion, H2S release, evacuation.
Procedures documented in an Emergency
Procedure Manual which is widely distributed.
Frequency of conducting drills established.

3 BASIC SAFETY RULES No written Safety Safety rules have been Safety rules are incorporated Safety rules exist in handbook form, distributed to
(SAFETY MANUAL) manual developed in written form. in Safety Manual, but not in a employees. Disclipinary action procedures
format which is distributed to established for infraction or rules
employees

4 ACCIDENT REPORTING No written Accident Written procedures Written procedures requiring Procedures require accident reports to be procided
Reporting Procedures requiring basic reporting of reports on all accidents and to Operator's representatives. Supervisor
personal injuries only incidents. investigation required to determine and correct root
causes.

5 NEW EMPLOYEE No formal program Verbal instructions on Orientation booklet provided Employee handbook provided and supervisor
ORIENTATION company procedures only for new employees but no on- outlines, explains and demonstrates new
PROGRAM the-job orientation by the employee's job. Follow up observation of the new
supervisor. Language barriers employee work is included. Employee has had safe
are recognised. practices and emergency duties explained. Multi-
lingual program.

6 SAFETY MEETING No fromal program Periodic safety meeting for Safety meetings performed on In addition to "B" employees are assigned to
PROGRAM special operations only. a regularly scheduled basis by discuss on a rotational basis.
the supervisor of safety
representative.

7 SAFETY TRAINING No safety training On-site basic safety training safety training is given for Formal safety training programs have been
PROGRAM established conducted occasionally. specialised operations, but no developed and are conducted on a regular basis.
routine training conducted. Retraining periods are established.

8 SAFETY INSPECTION No inspection program Plan relies on outside
PROGRAM sources, i.e. insurance
company inspections. No
supervisory inspection of
work place.
A written program outlining In addition to "B", periodic inspections are
inspection guidelines, conducted by top management or by teams of
responsibilities, frequency and specialists.
follow-up in effect

9 PROFESSIONAL SAFETY None on the staff, no Safety is assigned to a Safety proffesional on staff. Safety proffesional on staff who routinely inspects
SUPPORT assignment to any specific person on location. Not routinely involved in operations monitors compliance and communicates
specific person. operations. findings.

Evaluation Criteria Page 2 of 5

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CONTRACTOR HSE EVALUATION CRITERIA Doc. Number: Doc. Number: KAS-HSE-FORM-03

A B C D
10 INDUSTRIAL HYGIENE & No industrial hygiene Basic policy exists but is A policy exists and recognize A policy exists which manages operations to
HEALTH policy exists. not enforced. hazards but is not followed minimize human health impacts providing a
up. workplace free of recognized health.

11 PERSONAL No personal protective Provides minimum personal Provides equipment but lacks Contractor furnishes all safety equipment, training
PROTECTIVE equipment. protective equipment. training and follow-up and clothing necessary for the protection of its
EQUIPMENT personnel.

12 ENVIRONMENTAL No environmental A policy exists. A policy exists which A policy which exceeds local regulations and
policy exists. complies with local complies with PSC expectations.
regulations.

13 EQUIPMENT AND No program exists for Basic program exists, but Program exists but not A regular program exist for inspection preventative
MATERIAL regular inspection and not applied and no record regularly applied and limited maintenance, operation acquisition and
MANAGEMENT preventative keeping. record keeping. certifications. Good record keeping.
maintenance.

14 STATISTICAL INCIDENT No statistical and injury Lacks statistical data. Minimum statistical data. Has historical data for past three years. Trends are
AND INJURY DATA data exists. Trends are increasing or Average performance decreasing and relative position in industry is high.
rate is significantly above compared to industry.
the industry norm.

15 INCIDENT No procedures or Basic procedures exist but Has procedures but is Recognizes and records actual near-miss incidents.
INVESTIGATION process established to there is no follow-up. deficient in several areas that Investigates incidents to root causes through
investigate incidents. can be corrected through established procedures. System exists to track all
Near-misses not changes in existing programs. close out findings.
recognized.

16 SUB CONTRACTORS No evidence that sub- Sub-contractor's EHS Evidence that the sub- Evidence that sub-contractors are evaluated on
contractor's EHS performance is irregularly contractor's safety safety performance as part of the selection process.
performance is reviewed. No record performance is taken into Joint participation with sub-contractor in safety
considered. keeping. account in the selection management throughout the organization.
process. Some statical
tracking of sub-contractor
safety performance.

17 OTHER

Evaluation Criteria Page 3 of 5

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CONTRACTOR'S SAFETY Doc. Number: KAS-HSE-FORM-03

PROGRAM EVALUATION

Contractor :
Address :
Date :
Contractor Safety Contract :
Phone :

Circle the number which best represents this evaluation based on the criteria for rating purposes
attached.

A B C D COMMENT
A. PRIMARY FACTORS

Policy Statement 0 3 7 10
Emergency Response Procedures 0 3 7 10
Basic Safety Rules (Safety Manual) 0 3 7 10
Accident Reporting Procedure 0 3 7 10
New Employee Orientation Program 0 3 7 10
Safety Meeting Program 0 3 7 10
Safety Training Program 0 3 7 10
Safety Inspection Program 0 3 7 10
Personal Protective Equipment (PPE) 0 3 7 10
Equipment & Materials Management 0 3 7 10
Total Rating ____ + ____ + ____ + ____ X 0.70 = Rating

A B C D COMMENT
B. SECONDARY RATING

Professional Safety Support 0 5 11 15

Industrial Hygiene 0 6 14 20
Environmental 0 6 14 20
Satistical I & I Data 0 3 7 10
Incident Investigation 0 5 11 15
Sub-Contractors 0 6 14 20
Total Rating ____ + ____ + ____ + ____ X 0.30 = Rating

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CONTRACTOR'S SAFETY Doc. Number: KAS-HSE-FORM-03

PROGRAM EVALUATION

SUMMARY
The numerical values below are the weighted ratings calculated above. The total represents the overall
score for the Contractor.

A. PRIMARY FACTORS :
B. SECONDARY FACTORS :
TOTAL RATING *) :

EVALUATED BY:

NAME NAME
TITLE TITLE
DATE DATE

*) FOR BIDDER TO QUALIFY AS ACCEPTABLE, THE TOTAL RATING MUST BE EQUAL OF MORE THAN 50.3 IF
INSUFFICIENT NUMBERS OF BIDDERS ARE QUALIFIED, SELECTION SHALL BE MADE FROM THE FIVE BIDDERS
HAVING THE HIGHEST TOTAL RATING, PROVIDED THAT THE PRIMARY FACTORS THE

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