Form: Vendor HSEQ Questionnaire Form

G-PR-FM- Procurement8db234b3-cd5c-
Document ID: Process Area: Version: 6.0
04542 444e-871c-88d55cbcd6e5

Part A - Workplace Health and Safety (WHS)

1 Certified WHS Management System
Can you provide current evidence of an independently certified WHS Management System in
Yes No
accordance with AS/NZS 4801 or its equivalent?
If ‘yes’ please provide a copy of your certificate of conformity for the WHS Management System and continue to
Section 3.

2 Non Certified WHS Management System

Does your company have a WHS Policy? Yes No
Has the Policy been signed by senior manager(s) of the company? Yes No
Does your WHS Management System document the following:
(a) WHS roles and responsibilities Yes No
(b) Process for incident reporting and investigation Yes No
(c) WHS risk management/assessment methodology Yes No
(d) Emergency preparedness and response Yes No
(e) Control, safe handling and disposal of all hazardous chemicals Yes No
(f) Consultation and communication, including WHS committees Yes No
(g) Management of plant and equipment Yes No
(h) Injury management and rehabilitation Yes No
(i) Workplace inspection and performance monitoring Yes No
If ‘yes’, you may be required to supply a copy of your procedures or WHS Management Manual.

3 WHS Competency and Performance History

Does your company have written procedures or processes for identifying and maintaining WHS
Yes No
training and competency requirements?
Does your company, employees and/or subcontractors have the relevant licences, permits,
Yes No
authorities, certificates, training, etc. required to provide the goods and/or services?
If ‘yes’ please attach certified copies of the relevant licences, permits, authorities, certificates, training, etc.
Have you ever had any of the following issued to you under any WHS legislation:
(a) Prosecutions Yes No
(b) Improvement notices Yes No
(c) Prohibition notices Yes No
(d) Enforceable undertaking Yes No
If ‘yes’ to any of the above please attach details.
Specify number of Fatalities for the last 5 financial years. 2015/16
2016/17
2017/18
2018/19

2019/20

Specify Lost Time Injury Frequency Rate for the last 3 financial years. 2017/18
2018/19

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Form Name: Vendor HSEQ Questionnaire Form
Document ID.: G-PR-FM-04542
Process Area: Procurement8db234b3-cd5c-444e-871c-88d55cbcd6e5

3 WHS Competency and Performance History

2019/20
Specify Medical Treatment Injury Frequency Rate for the last 3 financial years. 2017/18
2018/19
2019/20

4 High Risk Activities

Does your proposed method of delivery of the goods and/or services include any activity that involves:
(a) Working at heights Yes No
(b) Electrical works Yes No
(c) Working with Live Electricity Yes No
(d) Demolition works Yes No
(e) Excavations and Trenches Yes No
(f) Working near Underground Services Yes No
(g) Working in or near Live Traffic Yes No
(h) Crane Lifting Yes No
(i) Working in Hazardous Gas Areas, including Hot work Yes No
(j) Working alone at a construction site Yes No
(k) Asbestos related work Yes No
(l) Hazardous substances / chemicals Yes No
(m) Confined Space Entry Yes No
(n) The use of explosives Yes No
(o) Carrying out services on or near pressurised gas mains or piping Yes No
(p) Engaging subcontractors to complete the goods and/or services Yes No
(q) Working with and around High Risk Plant Yes No
If ‘yes’ you may be required to supply a sample copy of your safe work method statement and risk assessment.

Part B - Environment
1 Certified Environmental Management System
Can you provide current evidence of an independently certified Environmental Management System
Yes No
(EMS) in accordance with AS/NZS ISO 14001?
If ‘yes’ please provide a copy of your certificate of conformity for the EMS and continue to Section 3.

2 Non Certified Environmental Management System

Does your company have an Environmental and Sustainability Management Policy?
Yes No
If ‘Yes’ – please supply, and indicate an example of its implementation
Has the Policy been signed by senior manager(s) of the company? Yes No
Does your Environmental Policy demonstrate commitment to the environment and understanding of
Yes No
environmental obligations under legislation?
Does your company have qualified and experienced environmental resources that are responsible
for ensuring compliance with environmental requirements? Yes No
If ‘Yes’ please attach a brief resume of the nominated environmental resource/s

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Form Name: Vendor HSEQ Questionnaire Form
Document ID.: G-PR-FM-04542
Process Area: Procurement8db234b3-cd5c-444e-871c-88d55cbcd6e5

2 Non Certified Environmental Management System

Do you have mitigation strategies in place to reduce environmental risks?
If ‘Yes’ – what are some example mitigation strategies used by the company? Attach relevant Yes No
supporting evidence with the tender submission
Do you have documented procedures to handle an environmental incident? Yes No
Do you undertake waste audits, environmental audits or monitoring programs to minimise
Yes No
environmental impacts?
Will all fuels, solvents, chemicals and materials to be used, be stored and disposed of in a manner
Yes No
complying with Environmental Legislation?
Does your company demonstrate a commitment to waste reduction, recycling, energy efficiency and
greenhouse gas emissions reductions? Does your company collect, keep track of and report the
information required in respect of its greenhouse gas emissions, energy production and energy Yes No
usage?
If ‘Yes’ please attached relevant supporting evidence
Does your company provide a material and/or product range that has an environmental label from
sustainable supply chain?
Yes No
If ‘Yes’ you may be required to provide details of your environmental labelled products and/or
sustainable supply chain
If your company a registered user of the sustainable Supply Chain Sustainability School?
Has your company undertaken the online self-assessment tools to help you assess your company’s
current sustainability knowledge and strengths, and to identify areas in which you can develop your
competence? Yes No
If ‘No’ please undertake the assessment and provide a copy of your “prioritised company action
plan”
If ‘Yes’ please provide evidence
Does your business have initiatives in place directed towards meeting social and ethical
responsibilities (i.e. indigenous engagement, workplace diversity, community partnerships, etc.) Yes No
If ‘Yes’ please provide details
If ‘yes’, you may be required to supply a copy of your procedures or Environmental Management Manual.

3 Non Certified Environmental Management System

Does your company have written procedures or processes for identifying and maintaining
Yes No
Environmental training and competency requirements?
Does your company, employees and/or subcontractors have relevant Environmental Approvals,
Yes No
Licenses or Permits required to provide the Goods/Services?
Have you ever had any of the following issued to you under any environmental legislation:
(a) Prosecutions Yes No
(b) Improvement notices Yes No
(c) Prohibition notices Yes No
(d) Fines / Infringements Yes No
It is acknowledged by the Vendor that the following attachments to this document, being the: 1)
Purchasing Data; 2) Waste Data and 3) Energy consumption Monthly Process Report as indicated in
Yes No
the Schedule Guidelines must be submitted to the Contractor on a monthly basis. The Vendor must
tick the box in acknowledgement of the requirement.
If ‘yes’ to any of the above please attach details.

Part C - Quality
1 Certified Quality Management System
Can you provide current evidence of an independently certified Quality Management System (QMS)
Yes No
in accordance with AS/NZS ISO 9001?
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Form Name: Vendor HSEQ Questionnaire Form
Document ID.: G-PR-FM-04542
Process Area: Procurement8db234b3-cd5c-444e-871c-88d55cbcd6e5

1 Certified Quality Management System

If ‘yes’ please provide a copy of your certificate of conformity for the QMS and continue to Section 3.

2 Non Certified Quality Management System

Does your Quality Management System document the following procedures:
(a) Document and data control Yes No
(b) Purchasing Controls Yes No
(c) Control of client supplied product Yes No
(d) Product identification and traceability Yes No
(e) Quality Work Process controls Yes No
(f) Inspection and testing Yes No
If ‘yes’, you may be required to supply a copy of your procedures or Quality Management Manual.

3 Quality Competency and Performance History

Does your company have written procedures or processes for identifying and maintaining Quality
Yes No
training and competency requirements?
Does your company have an understanding of, and can comply with, legislative requirements,
Yes No
standards and codes of practice relating to the good and/or services provided?
From a formal quality audit completed in the last financial year, how many of the following were identified:
(Major) Non Conformance Record (NCR)
Minor NCR
Observations
If ‘yes’ to any of the above, you may be required to provide a copy of the audit report.

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Endorsed By:

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