APPENDIX 1

TENDER NO. : CHO/2019/BTS-31/1001

TENDER TITLE : PROVISION OF GAS & LIQUID ULTRASONIC METER (USM) RECERTIFICATION AND
RECALIBRATION FOR PETRONAS CARIGALI SDN BHD

SUPPLIER QUESTIONNAIRE – SUPPLIER FORM

GUIDELINES FOR TENDERER FOR PREPARATION OF RESPONSE TO QUESTIONNAIRE

INTRODUCTION
1 The purpose of this Questionnaire is to obtain information required to assess the extent to which
HSSE and its management are organised by the Bidder.

2 All questions must be answered. Please answer each question fully. We wish to stress that answers
are to be substantiated by supporting documentation as far as is practicable and when requested by
the Company. Responses and any supporting documentation must relate specifically to the policy and
organisational arrangements of the Bidder that would be the signatory of the Contract.

3 HSSE Key Performance data (HSSE KPI) in relation to all Bidder’s works for the current and previous
four (4) years must be provided. Bidder’s submission of HSSE KPI should not be limited to Bidder’s
work. The glossary of terms for KPIs is also attached in this document for reference.

4 Your submission will be assessed and its value will be taken into consideration in the evaluation
process leading to a CONTRACT award decision.

5 Following receipt of your submission, we may wish to further clarify with your management. Company
also reserves the right to conduct site inspection at a mutually convenient time to verify the supporting
evidence submitted.

6 Your answers to these questions will form an integral part of any Contract entered into between the
Bidder and the Company as a result of this HSSE assessment.

7 Your submission to this Questionnaire shall be in the same excel spreadsheet format in
electronic copy and do not pdf. However, evidences supporting the responses can be
submitted in hardcopy.

COST RELATED TO CLOSE HSSE GAPS

1    Bidder is required to close any HSSE Gaps identified based on the HSSE assessment via the
development and implementation of Contract HSSE Plan.

Please tick:

Have studied, understood and will comply with Article 15: Health,Safety and Environment
Requirements and Exhibit V of the Bid Document. All costs required to close any HSSE gaps
identified have been factored into the CONTRACT Price.

Have studied and understood but cannot comply with Article 15: Health,Safety and Environment
Requirements and Exhibit V of the Bid Document.

DECLARATION

I hereby declare that the facts and figures provided in this questionnaire are  true and correct.  

NAME OF
: ...............................................................................................................
BIDDER

SIGNATURE : ...............................................................................................................

NAME : ..............................................................................................................

POSITION : ...............................................................................................................

DATE : ...............................................................................................................

* The party endorses this questionnaires shall be from the highest management in the company
Open
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
HSSE stands for Health, Safety, Security & Environment
Please cover all aspects in your responses to the questions Response
Keyword Question Document
1 Leadership & HSSE Culture
How are senior managers
Example of Documents/Evidences:
personally involved in HSE
a) management for example 1. Agenda/MOM for HSE meetings include MOM - Kick off Meeting. Pease refer attachment
attendance by senior management.
objective-setting and monitoring?

Example of Documents/Evidences:
1. HSE meeting structure showing
Provide evidence of commitment
b) at all levels of the organisation? involvement of all staff in HSE meetings. MOM - Monthly Saftey Awareness Plan Talk attached
2. Minutes of meetings showing attendance
Committment to HSE by all staff.
aspects through 1.1
leadership Example of Documents/Evidences:
1. Evidence of communication and
consultation through various avenues, eg
HSE meetings, staff engagements, etc.
How do you promote a positive
c) culture towards HSE matters? 2. Reports or relevant supporting document Attached Weekly HSE & Work Project Progress
that demonstate involvement of senior
leadership team in the company's HSE
activities/ programmes, i.e. safety
campaigns, safety day, site visits, etc.

2 HSSE Policy & Strategic Objectives

Does your company have an HSE
policy document? Example of Documents/Evidences:
a) If the answer is YES please attach 1. HSE Policy statements LTB HSE Policy. Please refer attachment
a copy.

Who has overall and final

Example of Documents/Evidences:
b) responsibility for HSE in your 1. HSE Policy statements
LTB Managing Director, Asri Othman will Have the final responsbility
organisation?
HSE Policy Documents

Who is the most senior person in

the organisation responsible for Example of Documents/Evidences:
this policy being carried out at the 1. Evidence of Letter of Appointment issued Please refer to Memo attached. Our Technical Manager will responsible to carry out the
c) premises and on site where his by the CEO/MD stating the incumbent's policy
employees are working? Provide roles and responsibilities.
2.1 name and title.
Example of Documents/Evidences:
1. Evidences (Copy of emails issued to staff,
Itemise the methods by which you
minutes of HSE meetings, HSE induction
have drawn your policy
d) statements to the pack, pictures of locations in Company Policy statement displayed in office at working area entrance
premises) where the policies are displayed,
attention of all your employees?
included in Company's HSE MS Manual
(where applicable).

Example of Documents/Evidences:
What are your arrangements for 1. Evidences (Copy of email advising of the
e) advising employees of changes in change, minutes of HSE meetings) where Details cascade thorugh emails and memo. Plese refer Memo in attachment
the policy? the changes are being discussed, pictures
and/or reports of staff engagement.
Does your company have
Example of Documents/Evidences:
strategic HSE objectives?
HSE contract

a) If the answer is YES please attach 1. HSE Plan to include statements on HSE MS Plan Attached
objectives
strategic

strategic HSE objectives.

a copy.
2.2
Itemise the methods by which you
Example of Documents/Evidences:
have communicated your strategic
b) HSE objectives to the attention of 1. Copy of emails issued to staff, minutes of HSE Plan communicated through emails
HSE meetings/ awaydays, HSE Plan.
all your employees?
Organisation, responsibilities, resources, standards and
3
documentation
Example of Documents/Evidences:
1. HSE team in organisation structure
Organisational structure for HSE management

How is your organisation reports directly to CEO/MD.

a) structured to manage and 2. Roles & responsibilities and competency Please refer LTB HSE Organization Chart
communicate HSE effectively? for HSE team defined.
3. Training matrix for HSE critical roles, HSE
meeting structures, etc
Example of Documents/Evidences:
Do HSE meetings promote HSE
b) awareness? 1. Agenda for HSE meetings, minutes of MOM - Monthly Saftey Awareness Plan Talk attached
HSE meetings, etc

Example of Documents/Evidences:
3.1 1. Attendance list for kick-off meetings.
2. Contract HSE Plan include the
Do client and contractor meet arrangement for regular review, minutes of Please refer LTB HSE Organization Chart attached
c) regularly to discuss and action HSE meetings, reports of visits (including Please refer to MOM-Kick off meeting for Air Dyer Replacement Project and PASR
any interface situations? client's representatives) carried out at Shutdown Checklist
contractor's office, etc
3. Also attendance list and MoMs of
quarterly reviews of HSE Plan carried out.

What provision does your

Example of Documents/Evidences:
company make for HSE
1. HSE MS include HSE meeting structures,
d) communication meetings? HSE Plan include regular HSE meetings
We are yet to include meeting structures in our HSE MS and Plan
Please provide an organisation
planned, HSE induction for newcomers
chart
agers, supervisors and HSE critical positions

Example of Documents/Evidences:
1. HSE roles and responsibilities defined in
Have the managers and
job description.
supervisors at all levels who will
2. HSE tasks and targets agreed in annual
plan, monitor, oversee and carry
performance appraisal.
a) out the work received formal HSE 3. HSE training needs identified and training
LTB has no formal record for HSE training plan
training in their responsibilities
plan scheduled.
with respect to conducting work to
4. Training matrix for HSE certified persons
HSE requirements?
5. Letter of appointment for HSE roles/
positions (where applicable)

If YES please give details. Where

the training is given in-house
Example of Documents/Evidences:
please describe the content and
b) duration of courses. Please 1. Training matrix, training plan, quarterly LTB has no formal record for HSE training plan
monitoring of training plan reports
provide an example of training
3.2 matrix.

Open
 HSE training of managers, supervisors and HSE critical positions
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
HSSE stands for Health, Safety, Security & Environment
Please cover
3.2all aspects in your responses to the questions Response
Keyword Question Document

How have you identified areas of

your company’s operations where
Example of Documents/Evidences:
specialised training is required, for
c) instance training related to health 1. Procedure for identifying training needs, LTB has no formal record for HSE training plan
training matrix, etc
hazard such as radiation,
asbestos and chemicals?

What specialist HSE resources

Example of Documents/Evidences:
d) does your organisation have 1. HSE MS, company portfolio, etc
Please refer to LTB HSE MS Attached
available?
How does your company provide
Example of Documents/Evidences:
e) HSE specialised training for HSE 1. HSE Training Plan LTB has no formal record for HSE training plan
staff?

Example of Documents/Evidences:
1. Interview/induction checklist contains HSE
What arrangements does your
elements.
company have to ensure new
2. Onboarding/ Familiarization pack include
a) employees have knowledge of information on HSE, eg HSE MS.
LTB has no formal HSE induction for new employee
basic industrial HSE, and to keep
3. HSE induction carried out and refresher
this knowledge up to date?
(where applicable). Job description and
tasks & targets to include HSE elements.
General HSE training

Example of Documents/Evidences:
1. Interview/induction checklist contains HSE
What arrangements does your
elements.
company have to ensure new
2. Onboarding/ Familiarization pack include
3.3 b) employees also have knowledge information on HSE, eg HSE MS.
LTB has no formal HSE induction for new employee
of your HSE policies, practices
3. HSE induction carried out and refresher
and company requirements?
(where applicable). Job description and
tasks & targets to include HSE elements.

Example of Documents/Evidences:
What arrangements does your 1. Interview/induction checklist contains HSE
company have to ensure new elements.
employees have been instructed 2. Onboarding/ Familiarization pack include
c) and have received information on information on HSE, eg HSE MS.
LTB has no formal HSE induction for new employee
any specific hazards arising out of 3. HSE induction carried out and refresher
the nature of the activities? (where applicable). Job description and
tasks & targets to include HSE elements.

Does your organisation have a

competence system in place? Example of Documents/Evidences:
a) If YES, please describe the scope 1. Formal HSE competence
Cometence

LTB has no formal HSE competence system

assurance

and content of your competence system/procedure

3.4 system.

Open
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
Cometence

HSSE stands for Health, Safety, Security & Environment

assurance

Please cover all aspects in your responses to the questions Response

Keyword 3.4 Question Document
What arrangements does your
Example of Documents/Evidences:
company have to ensure existing
b) staff HSE knowledge is up to 1. Individual competence profile LTB has no record for staff HSE competence
(assessment, gap closure plan)
date?
Does your company have a
contractor management process Example of Documents/Evidences:
a) or system? 1. Formal process system/procedure in LTB has no contractor management system
If yes, provide an outline of the contractor management
process.
How do you assess contractors, Example of Documents/Evidences:
Contractor management process

b) HSE competence or HSE 1. Sample of completed pre-contract award LTB has no contractor assesment
performance? contractors assessment
Example of Documents/Evidences:
1. Attendance list for kick-off meetings.
2. Contract HSE Plan include the
arrangement for regular review, minutes of
Where do you define the company
HSE meetings, reports of visits (including
3.5 c) standards you require your client's representatives) carried out at
LTB has no contractor management system
contractors to meet?
contractor's office, etc
3. Also attendance list and MoMs of
quarterly reviews of HSE Plan carried out.

Example of Documents/Evidences:
1. Audit on contractors.
2. Contract HSE Plan include the
arrangement for regular review, minutes of
How do you ensure these
d) standards are met and verified? HSE meetings, reports of visits (including LTB has no contractor management system
client's representatives) carried out at
contractor's office, etc
3. Also attendance list and MoMs of
quarterly reviews of HSE Plan carried out.

Example of Documents/Evidences:
How do you identify new industry
1. Written HSE perfromance standards to
a) or regulatory standards that may cover all hazardous operation and basic Not available
be applicable to your activities?
HSE standards

requirement
Is there an overall structure for Example of Documents/Evidences:
b) producing, updating and 1. Formal process/system of updating Not available
3.6 disseminating standards? standards

Are your company standards

Example of Documents/Evidences:
aligned with OGP/industry
c) guidelines or recommended 1. External certifications, i.e. ISO9000, Not available
ISO14001 or OHSAS18001
practices? If yes state which one.

4 Risk Management Not available

Example of Documents/Evidences:
1. HSE MS Manual Document
How does your company identify
2. Hazard & Effect Register.
hazards, assess risk, control and
Risk Assessment & 3. Environmental Aspect & Impact Register, Please refer to LTB HSE MS page 20-24
4.1 a) mitigation CHRA/HRA. and JHA of replacement air dryer project attached
Control consequences, to a level as low
4. Sample of completed JHA, Risk
as reasonably practicable?
Assessment report, PTW, or other relevant
risk assessment reports.

Example of Documents/Evidences:
1. Copies of applicable HSE 'daughter'
policies relevant to health management.
Do you have specific policies and
2. Health management process and
programmes on specific health
programmes
a) hazards e.g. substance abuse, 3. Applicable health promotion,
Please refer to LTB Drug & alchol policy statement attached
blood borne thogens, malaria
communications, campaigns, etc.
pandemic diseases etc.
4. Reports on remedial action plans on
CHRA/HRA monitored until closure
Health Hazards

(evidence attached).

What type of health hazards

4.2 (chemical, vibration, noise, Example of Documents/Evidences:
radiation, etc) are 1. Copies of CHRA/HRA. Health
associated with the scope of your programmes included in HSE Plan.
b) services? Explain how 2. Copies of applicable monitoring reports,
Not available
occupational health eg noise monitoring report, workers' medical
hazards are identified, assessed surveillance report.
and controlled.
What systems are in place to Example of Documents/Evidences:
control these hazards and monitor 1. Pre- and post medical programme.
the effectiveness of these Fitness to Work programme for applicable
c) controls? Is worker’s regular staff.
Not available
exposure monitoring part of these 2. Medical surveillance and health
systems? monitoring is included in HSE Plan.

What type of safety hazards

Example of Documents/Evidences:
(mechanical guarding, work at
1. Records of HAZID carried out.
height, lifting and hoisting, Refer JHA Replacement of Air Dryer
a) confined space entry, explosive 2. Hazard and Effect Register to address
scope of activities carried out. Where Refer JHA USM Change Out Activity
atmospheres etc.) are associated
Safety hazards

applicable SoPs in place.

with the scope of your services?

4.3

Open
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
HSSE stands for Health, Safety, Security & Environment
Safety hazards

Please cover all aspects in your responses to the questions Response

Keyword Question Document
4.3 Example of Documents/Evidences:
1. Evidence of leading and lagging indicators
What systems are in place to in HSE Plan. HSE activities, eg toolbox talk,
control these hazards and monitor site inspections, behavioral safety Refer HSE MS Replacement of Air Dryer page page 7
b) the effectiveness of these programmes in place (eg ACT auditing). Toolbox meeting attendance list Air Dryer Replacement Project
controls? 2. Relevant SoPs in place addressing the
identified hazards in the Hazard & Effect
Register.

What type of logistics hazards

Logistics hazards

Example of Documents/Evidences:
(land transport, air transport,
1. Hazard & Effect Register and HSE MS Please refer HSE MS Replacement of Air Dryer page page 13
a) marine transport, materials Manual include addressing applicable and JHA Replacement of Air Dryer page 2
handling etc.)are associated with
logistics hazards.
the scope of your services?
4.4
What systems are in place to
control these hazards and monitor Example of Documents/Evidences:
b) the effectiveness of these 1. Applicable SoPs, assurance plan in place.
Please refer JHA Replacement of Air Dryer page 2
controls?
What type of environmental
hazards (chemical spill,
Example of Documents/Evidences:
Environmental

a) atmospheric emissions, waste 1. Environmental Aspect & Impact Register

Please refer to LTB HSE MS page 34-45
disposal etc.) are associated with
hazards

the scope of your services?

4.5
Example of Documents/Evidences:
What systems are in place to
1. Environmental Management Plan,
control these hazards and monitor
b) the effectiveness of these applicable SoPs, eg Waste Management LTB is yet to experience with environmental waste control scope
Procedure, assurance plan in place.
controls?
2. ISO 14001 certification (if available).
What type of security hazards Example of Documents/Evidences:
Security hazards

(terrorism, hostage taking, 1. Comprehensive Security programmes

a) robbery, hostile local population 2. Provide evidence of Security Risk Not available
etc.) are associated with the Assessment done (if available).
4.6 scope of your services? If not available, state "Not available".
What systems are in place to Example of Documents/Evidences:
control these hazards and monitor 1. Evidence of Security Procedure in place
b) the effectiveness of these (if available).
Not available
controls? If not available, state "Not available"
Example of Documents/Evidences:
Social responsibility

1. Comprehensive Social Responsibility

What type of social hazards are
programmes
a) associated with the scope of your 2. Provide evidence of Social Risk Not available
services?
hazards

Assessment done (if available).

4.7 If not available, state "Not available".
Example of Documents/Evidences:
What systems are in place to
1. Evidence of Social Performance Plan in
control these hazards and impacts
b) and monitor the effectiveness of place and implementation monitored, Not available
assurance audit carried out (if available).
these controls?
2. If not available, state "Not available".

5 Planning & Procedures

Do you have a company HSE-MS

manual (or operations manual
with integrated HSE requirements)
which describes in detail your Example of Documents/Evidences:
company approved HSE working 1. HSE Manual Index (Table of Contents)
HSE operations manual 5.1 a) practices relating to your work 2. Inventory of HSE procedures supporting
Please refer HSE MS Plan Table of Content attached
activities? the HSE MS.
If the answer is YES please attach
a copy of an index and relevant
supporting documentation.

Example of Documents/Evidences:
1. HSE Regulatory Compliance Register.
How do you ensure that
Review of register included in HSE Plan.
infrastructure, plant and
2. Copies of review carried out. PTI, PTO,
equipment used within your
CoFs (where applicable) register maintained.
Infrastructure and operations (own premises, client LTB is yet to have record tracking for equipment inspection but we do inspect equipment
5.2 a) site, or at other locations) are DOSH inspection schedule.
equipment integrity 3. Written programme outlining with 3rd party inspection body
correctly certified, registered,
requirements, responsibilities, frequency &
controlled and maintained in a
follow-up is in effect, together with periodic
safe working condition?
inspections conducted by management or
specialist.

Example of Documents/Evidences:
How do you manage changes and
1. Attach applicable MoC procedures and
assess associated risks e.g.
Management of change 5.3 a) personnel, equipment, processes, processes (incl relevant revisions), copies of Not available
MoC form used, record of reviews and
documentation?
communications (where applicable).

Example of Documents/Evidences:
1. Attach copy of Emergency Response
Emergency planning and response

Procedures in place (incl relevant

emergency scenarios), record of
communicating to staff, emergency drills
What arrangements does your carried out, remedial action plans from drills'
Refer HSE MS Replacement of Air Dryer page 17-18 and 26-27
a) company have for emergency findings being tracked and closed out.
Emergency & response plan based on project basis
planning and response? 2. Roles and responsibilities for staff
involved in emergency response defined and
relevant trainings provided (provide copies
5.4 of these trainings).
3. Layout of emergency response team set-
up and records of the resources available.

Example of Documents/Evidences:
1. Evidence of emergency response
Which emergency situations are scenarios included in emergency response
b) included? procedures/plans (which further defines how
Refer HSE MS Replacement of Air Dryer page 17-18
the scenarios are identified in relation to the
work activities).

6 Implementation and performance monitoring

Open
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
HSSE stands for Health, Safety, Security & Environment
Please cover all aspects in your responses to the questions Response
Keyword Question Document
Example of Documents/Evidences:
1. Annual corporate HSE Plan available,
with record of frequent monitoring, status
updates & formal reviews of actions
implementation.
2. Provide records of communicating and
What arrangements does your tracking the activities to closure. Examples
organisation have for monitoring of communications can be daily morning
a) the implementation of your HSE- meeting reports, monthly HSE minutes of
Attached MOM for Monthly Safety Awareness Plan
MS? meetings. HSE meetings to cover the 8
elements of the HSE MS (reports of
management facility visits, site inspection
visits, ACT audit reports, HSE performance
data, training status, HSE campaigns, HSE
MS self-assessment results, Learning from
Incidents, HSE alerts, etc.
HSE-MS implementation and active performance monitoring of work activities

Example of Documents/Evidences:
1. Record of HAZID carried out, the
How does your company assure
mitigations put in place (can be in the form
the implementation of work
of procedures and rules).
procedures within your work-site
2. Copy of the company's Permit to Work
b) operations e.g. compliance with Procedure.
Please refer JHA Replacement of Air Dryer and Toolbox Meeting Attendance
procedures, toolbox talks, safety
3. HSE audits/inspection activities included
meetings, supervision, job
in annual HSE Plan and implemented
observations?
(provide records of tracking and
audit/inspection reports).

Example of Documents/Evidences:
1. HSE key performance indicators and
parameters identified in annual HSE Plan
and tracked regularly (provide records).
How do you monitor employee
Evidence of the performance communicated
HSE performance e.g. hazard
c) identification systems, HSE to the workers (eg EI, staff engagements, Not available
etc.)
participation?
6.1 2. At least 2 HSE element in workers annual
tasks and targets that are being tracked.
3. Records of attendance to applicable HSE
activities.

Example of Documents/Evidences:
1. Evidence of leading activities and leading
KPI's included in annual HSE Plan.
2. Stop Work Policy in place.
3. Evidence of Stop Work, implementation of
ACT (reports available and significant
What active HSE monitoring is
findings discussed and reviewed for Refer HSE MS Replacement of Air Dryer page 7
d) performed (i.e. where no incident
improving HSE).
has occurred)? Attached LTB Stop Work Polcy
4. Learnings and best practices from others
being shared and discussed.
5. Toolbox meetings implemented and
supervision/ inspection carried out when
work is in progress (especially the critical
activities).

Example of Documents/Evidences:
1. Evidence of a system to track incidents
and audit findings and the
procedure/process in place.
How do you report and correct
e) deficiencies identified? 2. Evidence of discussions and meetings Not available
carried out to discuss and agree remedial
action plans. Where applicable review of
procedures/places as a result of the audit
findings.

Open
 HSE-MS impleme
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
HSSE stands for Health, Safety, Security & Environment
Please cover all aspects in your responses to the questions Response
Keyword Question Document
Example of Documents/Evidences:
1. Provide evidence of the possible
How do you communicate the
communication mode, eg Employee
f) results of active performance Information (email), HSE Bulletin, HSE
Not available
monitoring to relevant personnel?
Newsletter, HSE Notice Board (provide
picture).

Example of Documents/Evidences:
Safety performance See separate spreadsheet called 1. HSE performance statistics/data for the
6.2 a) Contractor Assessment KPI Data last 5 years - to include leading and lagging Plese refer Appenidx A
indicators
indicators.
Example of Documents/Evidences:
1. Evidence of the procedure/process and
regular monitoring plan for health in the
How is health performance
a) monitored and recorded? annual HSE Plan (eg LTI, MTC, RWC, FAC). Not available

2. MoMs for HSE meetings monitoring the

performance.
Example of Documents/Evidences:
1. Evidence of the procedure/process and
How is environmental regular monitoring plan for environmental
b) performance monitored and performance indicator in the annual HSE Not available
recorded? Plan (eg flaring, waste tracking, etc).
2. MoMs for HSE meetings monitoring the
performance.

Example of Documents/Evidences:
1. Evidence of the procedure/process and
regular monitoring plan for security
How is security performance
HSE performance monitoring

c) monitored and recorded? performance indicator in the annual HSE Not available
Plan.
2. MoMs for HSE meetings monitoring the
performance.

Example of Documents/Evidences:
6.3 1. Evidence of comprehensive incident
reporting and follow-up procedure in place.
How and what near miss incidents
d) are reported? 2. Tracking database and system in place Not available
and reports of previous near-miss incidents.
3. Evidence of the learning from incident is
widely shared.

Example of Documents/Evidences:
1. Evidence/MOM of which the agenda
include review of HSE performance (should
How often is HSE performance
e) reviewed? By whom? align to HSE MS and/or HSE Plan Not available
requirements).
2. Evidence of attendance list to the
meetings.
Example of Documents/Evidences:
1. As above (where applicable).
How is logistics performance 2. Performance indicators specific to
f) monitored and reported? logistics' safety and/or including
Not available
implementation intervention, non-compliance
to Life-Saving Rules on Road Safety.
Example of Documents/Evidences:
1. If applicable, provide evidence of
g) Do you record vehicle incidents? notification, reporting and follow-up. Not available
Otherwise, put 'Not Applicable'.
Example of Documents/Evidences:
What types of HSE incident are
a) investigated? 1. Provide HSE incident investigation and Refer HSE MS Replacement of Air Dryer page 18
follow-up procedure.
HSE incident and investigation follow-up

Example of Documents/Evidences:
What process is used to
b) investigate HSE incidents? 1. Provide HSE incident investigation and Refer HSE MS Replacement of Air Dryer page 24 - Accident Report Form
follow-up procedure.
Example of Documents/Evidences:
Who conducts HSE incident
c) investigations? 1. Provide HSE incident investigation and For project based, site safety officer or on duty supervisor will conduct investigation
follow-up procedure.
Example of Documents/Evidences:
1. Provide HSE incident investigation and
6.4 How are the findings of an follow-up procedure.
incident investigation followed up 2. Evidences of the results of the incident
d) to ensure effective prevention of investigations shared with management,
There is no reported accidents to date
recurrence? lessons learnt from findings cascaded to
workforce and any remedial action plans
tracked to closure.

Example of Documents/Evidences:
1. Evidences of the various communication
How is incident learning
mode utilized for communicating this to the
e) communicated to all relevant workforce, eg Employee Information (by
Not available
personnel?
email), HSE Bulletin, HSE Newsletter, HSE
Alert, workshops, Townhall sessions, etc.

Has your company suffered any

statutory notifiable incidents in the
Example of Documents/Evidences:
last five years (safety,
Statutory notifiable 1. If any, provide details of statutory
occupational health and
notifiable incidents or notice of instructions
incidents or non 6.5 a) environmental)? served by the relevant regulatory bodies.
Not available
compliance notices Answers with details including
2. Also copies of fines, summons, etc. (if
dates, country and location,
applicable).
summary of incident and follow-up
preventative measures taken.

7 HSE auditing and management review of HSE-MS

Example of Documents/Evidences:
1. Copy of HSE Audit Procedure (if
Do you have a written procedure
available). Please refer to LTB HSE MS page 31-33
a) for HSE auditing? 2. Annual HSE Audit Plan
If yes, please attach a copy. The HSE Plan is no yet been audited
3. Provide sample of completed audit report.

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Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)
Supplier / Contractor LT BORNEO SDN BHD
Date of Assessment Sunday, October 20, 2019
Completed By NIZWAN / PROJECT ENGINEER
Required KPIs are listed on the 2nd tab
HSSE stands for Health, Safety, Security & Environment
Please cover all aspects in your responses to the questions Response
Keyword Question Document
Who is involved in conducting Example of Documents/Evidences:
HSE audits? How are audit team 1. Same as above
members selected to have 2. If audit plan in place (included in HSE
specific expertise and be Plan), to specify the audit sponsor, team Please refer to LTB HSE MS page 31-33
b) independent from the activities lead, team members, etc.
being audited? 3. Copies of auditors' qualifications, etc (if
What are the qualifications available).
Audits

7.1 required for auditors?

How does your company schedule

HSE audit and what scope of
Example of Documents/Evidences:
auditing is covered? e.g. internal,
1. Scope of audit to be included in the HSE
c) regulatory compliance, Audit Procedure (if available).
Not available
supplier/contractor, HSE
2. If not, state "Not available".
management system
implementation.

Example of Documents/Evidences:
How does management follow up 1. Audit methodology and analysis, action
d) on audit findings and ensure items tracking requirements to be included in Not available
effective close out of action items? the HSE Audit Procedure (if available).
2. If not, state "Not available".
Do you have a written procedure Example of Documents/Evidences:
Management review and follow-up

for management review of the 1. Section of HSE-MS on the requirement for

a) HSE-MS? management review.
Not available
If yes, please attach a copy 2. If not, state "Not available".

Example of Documents/Evidences:
1. If reviews done, provide evidence of the
discussions (in the form of minutes of
How often are HSE-MS reviews
meetings, results of the reviews and
b) conducted and who is involved in attendance list of personnel involved in the Not available
7.2 the process?
review).
2. The reviews should align to the frequency
stated in the HSE MS.

Example of Documents/Evidences:
How are identified actions and 1. Record of HSE minutes of meetings and
c) improvement efforts recorded and management reviews. Not available
tracked to effective completion? 2. Record of the tracking done until closure
of the action items.
8 HSE management - additional features
Example of Documents/Evidences:
1. Copies of any HSSE (valid) certificates
Please provide information on any
Certification of your HSE- achieved by the Company, eg OHSAS
8.1 certification which you have
18001, ISO 14001, ISO IEC 17025, ISPS
Not available
MS received from certification bodies
Statement of Compliance, etc
2. If not, state "Not available".
Example of Documents/Evidences:
1. Provide evidence (if available) company’s
Describe the nature and extent of
active involvement in relevant industry
Membership of your company’s participation in
8.2 bodies/organisation related to HSE. Not available
associations relevant industry, trade, and
2. Industry/client recognition/award for HSE
governmental organisations
initiatives and/or perfromance.
2. If not, state "Not available".

Does your organisation (globally, Example of Documents/Evidences:

regionally or locally) have any 1. Provide evidence if available.
Additional features of your
8.3 HSE features or arrangements not 2. Industry/client recognition/award for HSE Not available
HSE-MS described elsewhere in your initiatives and/or perfromance.
response to the questionnaire? 3. If not, state "Not available".

9 Company specific information

END

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TENDER TITLE : PROVISION OF GAS & LIQUID ULTRASONIC METER (USM) RECERTIFICATION AND
RECALIBRATION FOR PETRONAS CARIGALI SDN BHD

Supplier pre-qualification Questionnaire - HSSE Data

See Glossary of terms for definition of each item

EXPOSURE Current
Year -1 Year -2 Year -3 Year -4
Year
Total Manhours worked 1,512 1690 1610 1688
Exposure - Driving (km) 19000 19000 19000 19000
Exposure - Site Work (hours) 899 361 677 1020

SAFETY Current
Year -1 Year -2 Year -3 Year -4
Year
Fatalities FAT 0 0 0 0 0
Lost Time Incidents LTI 0 0 0 0 0
Lost Workday Cases LWC 0 0 0 0 0
Restricted Workday Cases RWC 0 0 0 0 0
Medical Treatment Cases MTC 0 0 0 0 0
First Aid Cases 0 0 0 0 0
Total Recordable Cases (sum FAT, LWC, TRC
MTC, or RWC) 0 0 0 0 0

Near Miss Incidents 0 0 0 0 0

Fatal Accident Rate (per 108 hours) FAR

0 0 0 0 0

Lost Time Injury Frequency (per 106 LTIF

hours) 0 0 0 0 0

Total Recordable Case Frequency TRCF

(per 106 hours) 0 0 0 0 0

ENVIRONMENT Current
Year -1 Year -2 Year -3 Year -4
Year
Loss of Primary Containment LOPC
(recordable) 0 0 0 0 0

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TENDER NO. : APPENDIX A

Glossary of Terms

1 Total Manhours Actual hours worked (not including non-work time such as sick leave or vacation) by all
Worked employees during the period.
2 Exposure – Driving km driven by all employees during the period
(km)
3 Exposure – Site Actual hours worked on construction, fabrication or operating sites during the period
Work (hours)
4 Fatality (FAT) A work-related injury or illness resulting in the death of the employee, even if death did
not occur immediately. Exclude fatalities due to self harm (e.g. suicide) or natural
causes.
(Equivalent to OSHA “Death”).
5 Lost Time Incident A work-related injury, not illness, that results in a Fatality (FAT) or Lost Workday Case
(LTI) (LWC).
(No OSHA equivalent)
6 Lost Workday Case A work related incident when an employee is injured and a doctor or licensed heath
(LWC) care practitioner prescribes days away from work. Count the number of calendar days
the employee is unable to work, excluding the day of the injury or onset of illness, not
just the days away from work, Count only full not partial calendar days.

(Equivalent to OSHA “Days Away from Work”)

7 Restricted Is a work-related injury or illness when:
Workday Case (i)       an employee is unable to perform one or more routine job functions – activities
(RWDC) the employee performs at least once per week; or
(ii)      is kept from working a full workday; or
(iii)     a licensed health professional recommends either of the above
Count the number of calendar days of restricted work, excluding the day of the injury
or onset of illness.
(Equivalent to OSHA “Restricted Work Activity”).
8 Medical Treatment A work related injury or illness requiring medical care beyond First Aid that is not a
Case (MTC) Lost Workday Case (LWC) or Restricted Workday Case (RWC) Exclude visits to
health care professionals solely for observation or counselling or diagnostic
procedures (X-ray, blood tests, prescriptions use solely for diagnostic purposes).
(Equivalent to OSHA “Medical Treatment beyond First Aid”).
9 First Aid Case The treatment of a work related injury or illnesses in one of 14 ways:
(i)       Using non-prescription medication at non-prescription strength
(ii)      Giving Tetanus immunisations
(iii)     Cleaning, flushing or soaking wounds on the surface of the skin
(iv)     Using wound coverings such as bandages, Band-Aids TM or gauze pads or
butterfly bandages or Steri-Strips TM
(v)      Using hot or cold therapy
(vi)     Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid
back belts etc.
(vii)    Using temporay immobilisation devices such as splints, slings, neck collars or
back boards while transporting the victim
(viii)   Drilling finger nail or toe nail to relieve pressure or draining fluid from a blister

(ix)     Using eye patches

(x)      Removing foreign bodies from the eye using irrigation or cotton swab
(xi)     Removing splinters or foreign material from areas other than the eye by irrigation,
tweezers, cotton swabs or other simple means
(xii)    Using finger guards
(xiii)   Using massages
(xiv)  Drinking fluid for the relief of heat stress

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 10 Total Recordable A work related injury, not illnesses, that results in Fatality (FAT), Lost Workday Cases
Cases (TRC) (LWC), Medical Treatment Case (MTC) or Restricted Workday Case (RWC).
(No OSHA equivalent).
11 Near Miss Incidents All potential incidents

12 Fatal Accident Rate Number of Fatalities (FAT) per 100 million manhours
(FAR)
13 Lost Time Incident Number of Lost Time Injuries (LTI) per million manhours
Frequency (LTIF)

14 Total Recordable Total Recordable Cases (TRC) per million manhours. Note this is also called Total
Case Frequency Recordable Incident rate (TRIR).
(TRCF)
15 Loss of Primary An planned or uncontrolled release of hazardous material (gas, liquid or solid) from a
Containment (LOPC) process or storage that serves as primary containment. Include all releases more than
10 kilograms Include material.

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