Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

TSSD-LS09-003
Regional Office No. 5
Rev. 02
Legazpi City
Effective: 20 Aug 2021

CHECKLIST OF REQUIREMENTS FOR CERTIFICATE OF APPROVAL OF CONSTRUCTION SAFETY AND HEALTH PROGRAM (CSHP)
GOVERNMENT INFRASTRUCTURE PROJECTS AND/OR PRIVATE CONSTRUCTION PROJECTS WITH 3M ABOVE BUDGET

Date: 3/27/2023

Name of Project: PROPOSED TWO STOREY RESIDENTIAL BUILDING

Location of Project: LOYOLA ST. MALILIPOT ALBAY
Contractor: N/A (by ADMIN)
Address: MALILIPOT ALBAY
Contact Details: CP# 0991-712-9658 E-mail: mbelmonte_2007@yahoo.com
DOCUMENTS SUBMITTED:
WHEN PERSONAL SUBMISSION IS PERMITTED: ALL documents for each project must be submitted in DUPLICATE and each fastened in a FOLDER.
Arrangement shall be in the sequence as presented below.
For ON-LINE SUBMISSION: The sending of scanned copy shall be in the sequence as presented below.
Check/Tick Applicable Box or Write N/A in the Remarks if not applicable
YES NO REMARKS
I. General Requirements
1. Letter of intent to apply for Certificate of Approval of CSHP detailing the list of
attachments
2. Name of authorized contact person with telephone numbers
II. The CSHP MUST contain the following:
1. Name of Person who prepared the program (Minimum requirement is SO2 & indicate
the accrediting OSH entity)
2. Project Description
a. specific name of project
b. location of the project
c. project classifications
d. project owner
e. name of main contractor, if any
f. estimated number of workers to be deployed Total: 9 male: female:
g.estimated start of execution of project JULY 3, 2023
h.estimated duration 365 CD
3. Company Safety Policy written on a company letterhead
a. Must be duly signed by the highest company official or the highest ranking
company representative who has over-all control of project execution.
4. Management/Owner's Commitment to comply safety and health policy
5. Composition of Safety and Health Committee (Per project.)
a. Must specify the proposed structure and names of member of the safety and
health committee
6. Names of site safety and health personnel (depending on the number of workers to
be deployed at the construction site)
7. Specific duties and responsibilities of the Safety Officer
SPECIFIC PROVISIONS ON THE FOLLOWING (if applicable)
8. On site safety and health promotion and continuing information dissemination
9. Accident and incident investigation and reporting
10. Protection of the general public within the vicinity of the construction site
11. Environmental control
12. Guarding of hazardous machinery
13. Personal Protective Equipment
14. Handling of Hazardous substances
15. General material handling and storage procedures
16. Workers’ skills and certification (for critical occupation)
17. Provisions for transportation facilities for workers in case of emergency
 18. Temporary fire protection facilities and equipment
19. First aid and health care medicines, equipment
20. Workers’ Welfare Facilities
21. Minimum wage and other statutory benefits
22. Proposed Hours of Work and Rest Breaks
23. Construction waste disposal
24. Testing and inspection of construction heavy equipment (if heavy equipment will be
utilized in the project per requirements of Sec. 10, D.O. No. 13)
25. Disaster and Emergency Preparedness contingency plan

YES NO REMARKS
26. Standards Operating Procedure and Job Hazard Analysis for the following activities
and other hazardous work not outlined herein:
a. Site cleaning
b. Excavations
c. Erection and dismantling of scaffolds and other temporary working platforms
d. Temporary electrical connections/installations
e. Use of scaffolds and other temporary working platforms
f. Working at unprotected elevated working platforms or surfaces
g. Use of power tools and equipment
h. Gas and electric welding and cutting operations
i. Working in confined spaces
j. Use of internal combustion engines
k. Handling hazardous and/or toxic chemical substances
l. Use of handtools
m. Use of mechanized lifting appliances for movement of materials
n. Use of construction heavy equipment
o. Demolition
p. Installation, use and dismantling of hoist and elevators
27. Penalties/Sanctions for violations of the provisions of the OSH Program
28. DPWH D.O. 39, s. 2020 Re: Revised Construction Safety Guidelines for the
Implementtion of Infrastracture Projects During the Covid-19 Public Health Crisis
III. ATTACHMENTS (Mode of Verification)
1. Duly Accomplished and signed Application Form
2. Photocopy of valid PCAB License (in case of pending application/renewal of license,
receipt of payment of fees or certification issued by PCAB is acceptable)
3. Photocopy of Registration of Establishment under Rule 1020 of OSHS
4. Notice of Award (NOA) (for government projects only)
5. Photocopy of Cert/s. of Completion on req. training of all designated OSH personnel
Safety Officer- with Construction Occupational Safety and Health Training for
Construction Site Safety Officer (COSH)
SO2 - with 1-9 workers (COSH training required)
SO3 - with 10-50 workers. Required a total of 88 hours specialized training on
safety and health ex: (40hrs. COSH + 40 hrs. LCM + 8hrs. BBS)
- with 51-199 workers: 1 SO2 & 1 SO3
- with 200-250 workers: 2 SO3
- every additional 250 workers: additional SO3 or SO4
OH Nurse (OHN) - with Basic Occupational Safety and Health Training for OH Nurse
(for those with more than 50 workers)
First Aider (FA) - Standard First Aid training with valid PRC ID as First Aider; or if
registered nurse, must have a training or cert. on Basic Life Support
 OH Physician (OHP) - Basic Course on Occupational Med. (with 100-199 workers)
6. Cert. of Insp. and Testing of heavy equipment by entity duly accredited by DOLE or
showing of warranty cert. that the unit/s is/are still under warranty of one (1) year
7. Valid skills cert. issued by TESDA to operator of heavy equipment (if using any)
8. Contract with nearby hospital/clinic in lieu of required infirmary hospital (whenever
or whichever is required)
9. Estimated OSH budget; PPEs quantify; and salaries of SO, OHN, FA, OHP indicated
whichever is required) indicated
10. Certification of Employment of SO, OHN, FA or OHP (whichever is required)
11. DPWH approved CSHP with DOLE RO5 concurrence (if applicable)
IV. RECOMMENDATION: Approval Concurrence Return Others

Evaluated by: In coordination with: Noted by:

EDUARDO PEDRO V. CAÑO MARY JANE L. ROLDA

(Signature over printed Name) CSHP RO Focal Person TSSD Chief
CLAIM STUB: FOR APPLICANT FOR DOLE RO5
Application No. Application No.
Received on: Time: Received on: Time:
Release on: Release on:
Name of Applicant/Rep.: Name of Applicant/Rep.:
CP#: CP#:
Email: Email:

Name & Sig of Evaluator: Name & Sig of Evaluator: