Approved Contractor Application - Non Prequal (Medium to High Risk)

Guidance

This form to be completed by contractors who are:

- new or are seeking a renewal; and
- are ‘Medium to High Risk’ Contractors e.g. those undertaking or managing physical work/operating machinery or otherwise exposed to work related safety risks beyond those expected for administrative work; and
- do not have a current health and safety prequalification e.g. Impac pre-qual

A separate ‘Low Risk’ application is available for contractors engaged to conduct administrative or consultancy work.

In completing this form consider your workers' privacy. Take care not to provide any identifying sensitive information about your workers or other parties. Redacted documentation will be accepted where appropriate.

Blank templates and generic health and safety policies will not be accepted.

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General Company Information

Company name *(required)

Trading as

Physical address

Postal address (if different to physical address)
Postcode Finder (new window)

Contact person

Contact person mobile

Contact person email (please type in a valid email address - name@domain, name.name@domain (eg name@name.co.nz, name.name@name.org etc)

Health and Safety Representative or Alternative Contact:

Health and Safety Representative or Alternative Contact: mobile

Health and Safety Representative or Alternative Contact: email (please type in a valid email address - name@domain, name.name@domain (eg name@name.co.nz, name.name@name.org etc)

Number of employees

Type of work

Please give a brief outline of the type of work or services your company undertakes (750 words maximum)

If other please specify (please provide the department name if it does not appear in the options list)

Other high risk work, please specify (please describe the high risk work if it does not appear in the options list. 500 words maximum)

Hazard Identification and Risk Management

Describe how risks are identified and managed in your company (500 words maximum)

How are workers consulted and provided opportunities to aid in the process of identifying hazards and managing risks? (250 words maximum)

Risk Register

How often are the risks and controls in your risk register reviewed and evaluated for effectiveness and updated? (500 words maximum)

Hazard or risk register documents Evidence: Attach your hazard or risk register here showing risks to workers’ safety, health and wellbeing. Your register should show the harm that could occur, risk rating before and after controls are in place and the expected controls. It should also show evidence of reviews.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Project/Job Specific Safety Planning

Examples of job/site specific safety planning Evidence: Please provide at least three examples of job/site specific safety planning, e.g. Task analysis (TA), site specific safety plan (SSSP), job safety analysis (JSA) - not greater than two months old.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Job safety planning evidence Evidence: For any high risk work identified in section 3 above, please provide job safety planning evidence where these high risks were present.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Hazardous Substance Register

Hazardous substance register Evidence: If you work with hazardous substances, please attach a copy of your hazardous substance register
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

PPE

Personal Protective Equipment (PPE) register Evidence: Please attach your up-to-date Personal Protective Equipment (PPE) register, e.g. register showing what has been issued inclusive of the date and when it was last inspected.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Training, Competency and Supervision

Training matrix evidence Evidence Please supply a training matrix for all workers showing current training. Please note this must include expiry dates, NZQA standard where relevant, and current first aid.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, .xlsx or .pdf type and no larger than 6.5MB in file size.)

Describe how you determine a worker is competent: (750 words maximum)

Emergency Management

You should have defined emergency procedures for sites that are not your central office base, e.g. construction site.

Emergency procedures for sites Evidence: Please attach examples of these emergency plans.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Where applicable, does your company have emergency response plans for high risk work e.g. work at height, confined spaces etc. Please describe. (500 words maximum)

Incident Management Reporting

Incidents, injuries and near misses must be investigated by your company.

Reports of investigation findings and corrective actions Evidence: Attach copies of recent reports complete with investigation findings and corrective actions.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Have you ever received any improvement/infringement/prohibitions notices, formal warnings from WorkSafe NZ or been prosecuted for breaches of health and safety legislation? (Within the last 24 months for renewal applications).

If yes, please provide details (Focus will be on your actions to improve after the infringement. 500 words maximum)

Improvement/infringement/prohibitions notices, formal warnings evidence Please load Improvements/infringement evidence as a file if needed. Focus will be on your actions to improve after the infringement.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Have you had any Notifiable events that have been reportable to WorkSafe NZ within the previous 24 months?

If yes, please provide details (500 words maximum)

Notifiable events evidence Please load Notifiable event evidence as a file if needed.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Continuous Improvement

Describe any work-related events (accidents/incidents or near misses) in the past 12 months that have led to positive changes or initiatives in how you undertake work. (500 words maximum)

Contractor Management

Do you engage contractors or subcontractors Please note: All sub-contractors engaged in work on DCC contracts MUST be DCC approved contractors in their own right.

How does your company consult, co-operate and co-ordinate with other PCBUs on projects (as lead contractor or as a sub-contractor) (500 words maximum)

Evidence of recently completed contractor inspection or audit Managing contractors involves checking work is being done as agreed. Usually this takes the form of audits and inspections.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size)

Planned Inspections and Audits

Describe and provide recent evidence of the maintenance/inspection programmes relating to your company’s fixed and mobile plant (including vehicles), equipment, power tools or other electrical equipment. (500 words maximum)

Examples of inspections (Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Do you have defined procedures for the isolation and lock-out of plant and equipment? (Hazardous Energy Sources)

Examples of completed isolations and lock-out procedures (Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Occupational Health Management

If other please specify

Outline your company’s occupational procedures for monitoring worker’s health (e.g. lung and hearing testing.) (500 words maximum)

Engagement and Consultation

How does your company engage with staff and allow them opportunities to identify and talk about health and safety issues? (500 words maximum)

Evidence of engagement and consultation e.g. health and safety meeting minutes, toolbox talks etc.
(Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 6.5MB in file size.)

Insurance

	Public Liability	Professional Indemnity	Motor Vehicle Third Party
Policy Number
Insurer
Expiry Date
Sum Insured

Insurance certificates (You can load up to 4 files by using the ‘Add more’ button. Each file must be a maximum size of 4MB.
Files may only be of .doc, .docx, .jpg, .jpeg, .xls, .xlsm, xlsx, or .pdf type and no larger than 4MB in file size.)

Declaration

General obligations *(required)

While a contractor is on the DCC Health and Safety Approved Contractors listing, the contractor must:

a) comply in all respects with New Zealand law governing Health and Safety including but not limited to:
- i) the Health and Safety at Work Act 2015 (HSWA) and any amendments or replacement legislation;
- ii) all regulations made under the HSWA; and
- iii) all relevant codes of practice;
b) immediately advise Council of any pending investigations, possible enforcement action, prosecution or fines, or improvement or prohibition notices that have been issued by WorkSafe NZ; and
c) advise the Council of the outcome of any enforcement action undertaken against them by WorkSafe NZ.

I will comply with the General Obligations set out above while I’m an Approved Contractor and acknowledge that the Council may suspend or cancel my approval status if I do not comply with the General Obligations.

Contractor Health and Safety handbook *(required)

Dunedin City Council Contractor Health and Safety Information Handbook

I have read and understood the “Dunedin City Council Contractor Health and Safety Information Handbook” and agree to abide by it.

Information provided is true, complete and correct *(required)

I declare that the information given by me on behalf of the company and any attached documentation is true, complete and correct. A false statement or dishonest answer to any question may be grounds for the immediate disqualification or termination from contracts/employment with Dunedin City Council. I agree to promptly notify Dunedin City Council if any of the information supplied changes.

Your privacy is important to the Dunedin City Council. Our Privacy Policy sets out how and why the DCC collects and stores your personal information, what we will use it for and with whom we can share it - Dunedin City Council Privacy Policy.

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