NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

Revised Form: CSHP Form 1A-2023:

 Department of Labor and Employment APPLICATION FORM
REGIONAL OFFICE NO. ________ FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

Legal Bases: Type of Construction Project:

1. Presidential Decree No. 442, as renumbered _____DPWH project
2. Republic Act No. 11058
_____Other Public/private construction project
3. Department Order No. 198, Series of 2018
(LGUs, other gov’t offices, private entities)

_____ Residential project engaging the services of

a construction firm

Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL CONTRACTOR/SUBCONTRACTOR/BUILDING OWNER in applying for a Construction Safety and Health
Program intended for a specific construction project.
Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with complete requirements and attachments will be processed.

A. Company Profile/License/Registration of Main/General Contractor

Complete Name of the Company/Main/ General Contractor/Project Complete Address of the Project
Owner Tel. No: __________________________________________________
Fax No. ___________________________________________________

Name of Project Manager/Owner/ Contact Person: Tel. No: ___________________________________________________

Email: _____________________________________________________

Contractor’s PCAB/JV License No: Number of workers:

________________________________ Male: _____ Female: _____ Total employment: _____

Date of Validity:___________________

Engaged Subcontractors’ Profile

Name of Sub-contractors (If any) Scope of Work and Project Cost No. of Workers PCAB License Date of Date of DOLE Registration
Validity

1.

2.

3.

4.

5.

6.

7.

(Use separate sheet, if necessary)

B. Project Profile/Description

Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or other documents indicating name and details of the project)

Complete Project Address/Location:

Name of Project Owner: Tel. No: _____________

Fax No: _____________
Email : _____________

Project Classification: Estimated No. of Workers to be deployed in the Date of Estimated Start/Execution of the project:

Total Project Cost:__________________ project:

___________________ ________/________/_________
(Workforce of the project to include workers of the Month Day Year
sub-contractor/s) Duration of the project (Pls. state the number of calendar days)
___________________________
 Department of Labor and Employment APPLICATION FORM
REGIONAL OFFICE NO. ________ FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary)

Revised Form: CSHP Form 1A-2023 Page 2 of 3

Date of Revision: 30 April 2023

Department of labor and Employment

APPLICATION FORM
REGIONAL OFFICE NO. ______
FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

OSH Personnel assigned to the project

Name Date of training Designated First Aider:

Designated Safety Officers: Name Date of ID Validity

(Please attach photocopy of Certificate of Completion on the Basic OSH Course for Construction Site Safety training

Officers issued by DOLE-BWC accredited Safety Training Organizations or recognized instit ution) Please attach a photocopy of the Certificate of First-Aid Training and valid First Aid ID from Phil Red
Cross, DOH, Bureau of Fire and DOLE- Accredited TVIs with TESDA registered EMS and other
DOLE-Accredited first aid training provider

Other OH personnel (if more than 50 workers will be deployed in the project)

Name Date of required BOSH Training

OH Nurse

OH Physician

Dentist

(If Heavy Equipment will be used in the Project)

 List of heavy equipment to be used in the Project: Name of Heavy Equipment Operator/s:

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.
(Please attach additional sheet, if necessary.) (Attach photocopy of skills certification from TESDA.)

Profile of the person who prepared the CSH Program for the abovementioned Project

___________________________ Educational Background:

Signature over printed name
Work Experience in OSH:

Other Qualifications:

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULNESS OF THE ABOVEMENTIONED INFORMATION. THE COMPANY HEREBY COMMITS TO STRICTLY IMPLEMENT THE ATTACHED
CONSTRUCTION SAFETY AND HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.
Submitted By:

Signature Over Printed Name of the Owner/Contractor Position Date

Assigned Evaluator

I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON THE DOLE PRESCRIBED CHECKLIST.
Evaluated By:

Signature Over Printed Name Position Date