Annexure - 1

JSW Contractor Pre-Qualification Questionnaire

Use of this self-assessment is mandatory as per Group Health & Safety Standard. You are free to ask for additional information.

Business Coated Site Coated - Bawal

1. Scope
This assessment is used by JSW to assess the extent its contractor’s development and commitment to OH&S. The questionnaire considers a wide range of requirements pertinent to OH&S and based on the
response, JSW will determine whether the contractor will qualify for any work at JSW site. Note : Compliance to Questions markerd in RED font are pre-requisite for the contractor to start work at site. (10
Mandatory requirements)
2. Contractor Details 3. Contractor Organisation (please provide copy of organisation chart)
Name: Mentech Key Roles Number Injuries/Illnesses 12 Month History
Postal Address: At-Dhubenchhapal (Near Prithwiraj Hotel) Managers 1 Fatal Incidents
Street Address: Po-Thelkoloi, Dist-Sambalpur, Pin-764210 (Odisha) Job Supervisors 4 Lost Time Injuries
Contact Person: Safety Sueprvisors 1 Lost Time Injuries Frequency Rate (LTIFR)
a) Title: Pandey Employees: High Skilled 3 Medical Treatment
b) Name: Hemanta Kumar Employees: Skilled 304 Number of Sites/Projects
c) Mobile No: 9937803555 Employees: Semi-Skilled 38 Disabling injuries
Company Phone & Fax: 9692128915 Employees: Un-Skilled 19 Near miss/near hit incidents
Company Website: [Link] Incidents causing property damage during
Contact Email ID: mentech2018@[Link] contract
Project or type of work: MBC,JBC,Project
Illness caused by workplace factors
Previous JSW Contracts: NA
3.1. Contractors Profile :- Contractors scope / Type of Work (Description of service):

3.2 Insurance (Mandatory requirement - Contractor not eligible to qualify, if any of these minimum legal requirement is not met)
Yes/No/NA Yes/No/NA
A Public liability insurance Covered? No D) Motor vehicle insurance available? Yes
B Professional indemnity insurance available? No E) Employers’ liability insurance available? Yes
C Product liability insurance available? No Provide evidence by showing a copy of your insurance policies.

YES / EVIDENCE ALIGNS

# DESCRIPTION - SECTION A NO / NA WITH JSW REQT.
SCORE

4 General OH&S Systems - Documents & Evidence

4.1 Policies
A Does your organization have a written health and safety policy? Yes Meets Requirement 3
B Does your organization have a Smoking, drug and alcohol policy? Yes Meets Requirement 3
C Does your organization have a written Environmental policy? Yes Meets Requirement 3
Provide evidence by supplying policies of relevant document
Sub group total 9 100%
4.2 Responsibilities
A Do you have an OHS organisation chart (with names) & their Job description? Yes Meets Requirement 3
B Has the organisation have written OHS responsibilities for all the below mentioned categories? Yes Meets Requirement 3
Management Yes
Supervisors Yes
No score for these
Employees / Workers Yes
sub-criterion
Subcontractor Employees Yes
Provide evidence by supplying policies of relevant document Yes
C Does your Site safety supervisor has recognised Health & Safety Qualification? (PGDIS, DIS, NEBOSH, Certificate Course) Yes Meets Requirement 3
Sub group total 9 3 100%
4.3 Training & Communication
A Does your organization have a formal employee induction program? (Induction module to be submitted to JSW) Yes Meets Requirement 3
B Does the written OH&S induction module include instruction on the following (as minimum):
1. All your OH&S policies Yes Meets Requirement 3
2. Incident Reporting Yes Meets Requirement 3
3. Roles & Responsibilities Yes Meets Requirement 3
4. Tool box meetings Yes Meets Requirement 3
5. Emergency procedures Yes Meets Requirement 3
6. First Aid facilities Yes Meets Requirement 3
7. Safety rules / Cardinal rules and consequences Yes Meets Requirement 3
8. Seat belt & mobile phone usage guidelines Yes Meets Requirement 3
9. Mandatory PPEs for different kind of activities. Yes Meets Requirement 3
10. Hazards associated with the respective nature of work Yes Meets Requirement 3
11. Learnings from past incidents Yes Meets Requirement 3
Does your organization have a process to record job specific health, safety, environmental training for employees? (submit training matrix as an
C No Meets Requirement 0
evidence)
D Does the training matrix include the following training programs? No Meets Requirement 0
1. Permit to work system No Meets Requirement 0
2. Fire Fighting No Meets Requirement 0
3. First aid No Meets Requirement 0
4. Mechanical Handling (Cranes, Hydras / any load handling equipment, MEWP etc,. ) No Meets Requirement 0
5. Working at Height (Use of life lines, Fall arrest system, Safety nets etc.,) No Meets Requirement 0
6. Manual Handling No Meets Requirement 0
7. Use of Power tools and Hand tools No Meets Requirement 0
8. Chemicals Safety No Meets Requirement 0
9. Driving safety No Meets Requirement 0
10. Hazard Recognition and control No Meets Requirement 0
11. Housekeeping (Including 5S) No Meets Requirement 0
12. Right use of PPEs No Meets Requirement 0
13. Any other Job Specific Training (like confined space entry, sand blasting / painting, Scaffolding, Electrical safety etc.,) No Meets Requirement 0
(Provide evidence of training contents of above modules)
E Does your organization have a qualified and competent trainers for above trainings? (Submit evidence) NA Meets Requirement
F Does your organization have a process to maintain records of employee induction & Training? (Submit record of any one site) No Meets Requirement 0
G Does your organisation have safety communication program at client site? Yes
1. Tool box talk Yes Meets Requirement 3
2. Self initiative of Mass Safety Communication / participation No Meets Requirement 0
3. Self Initiative of Various Safety Events and celebrations such as National safety day, World Health day, etc., / participation No Meets Requirement 0
Sub group total 39 31
4.4 Selection of sub-contractors (In the case of sub-cntractor is hired for the proposed job, in that case sub-contractors will also undergo the evaluation process)
A Does your organization have a process for selection of sub-contractor? NA Meets Requirement
B Is the performance of sub-contractors monitored as work is being undertaken? pl. select Not applicable if the job is not asigned to sub-contractors) NA Meets Requirement
Provide evidence by showing your process to engage subcontractors and monitor them during their work. NA
Sub group total 0 0
4.5 Health Monitoring
A Does your organization have a system in place to carryout medical fitness test prior to hiring? (submit the parameters for medical fitness) Yes Meets Requirement 3
B Does your organization have a system in place to monitor the health of employees at regular intervals? Yes Meets Requirement 3
Provide evidence by showing a copy of your medical fitness reports / Health checks (without disclosing any individual, personal data relating to an
employee).
Sub group total 6 2
4.6 OH&S Recognition
A Achievements / Awards recognised by clients / govt bodies / any ther bodies Yes Meets Requirement 3
B Do you have Safety Rewards & Recognition program at client site? Yes Meets Requirement 3
C Is your organisation Certified (OH&SAS 18001 / ISO 45001 & ISO 14001) No Meets Requirement 0
Provide evidence by showing a copy for each of the above
Sub group total 6 3
4.7 Plant and equipment
A When using plant and equipment either owned by you or from any other party (leased, hired, borrowed etc) do you have systems in place to ensure that:
1. All plant / equipment is fitted with safety devices as prescribed by legislation e.g. machine guards Yes Meets Requirement 3
2. Plant and equipment fitness certificate as per legislation is available & Valid? (Ex:- Crane test certificate, Earth moving equipment test certificate etc., NA Meets Requirement
3. Your employees have the correct licenses and/or certificates to operate the plant and equipment? Yes Meets Requirement 3
4. Your employees who are to operate the plant and equipment are trained in its safe use? Yes Meets Requirement 3
Provide evidence of training records and licenses/certificates of above
Does your Organization have in operation a method or system for recording regular inspections and maintenance of hand tools, machinery (cranes,
B Yes Meets Requirement 3
vehicles, boom lifts, hoists/lifting tools, etc) and electrically operated equipment? If so describe (attach details if additional space is required)
Sub group total 12 4
4.8 Accident / Incident Management
A Does your organization have an accident/incident reporting system? Yes Meets Requirement 3
B Does your organization have an accident/incident investigation process? Yes Meets Requirement 3
C Does your organization have a system to report incidents/accidents to the principal they are working for? Yes Meets Requirement 3
D Confirm that your organization has not been prosecuted for an OH&S violation in last 3 years? Yes Meets Requirement 3
Provide copies of your Accident/Incident management system as evidence
 Sub group total 12 4
4.9 Personal Protective Equipment (PPE)
A Has your organization assessed the jobs/tasks that require PPE? Yes Meets Requirement 3
B Does your organization provide/supply PPE to all employees as required? Yes Meets Requirement 3
C Does the PPE provided comply with IS codes and any other legal requirements? Provide Test certiicates / PO order Yes Meets Requirement 3
Provide evidence of your PPE requirements, compliance & Suplier information
Sub group total 9 3
4.10 Occupational Health & Safety management system
A Does your organization have the following safe work procedures in your safety plan / manual?
1. Fall protection Yes Meets Requirement 3
2. Scaffolding/working platform Yes Meets Requirement 3
3. Floor/wall/roof openings guards Yes Meets Requirement 3
4. Mobile equipment safety Yes Meets Requirement 3
5. Housekeeping Yes Meets Requirement 3
6. Fire protection Yes Meets Requirement 3
7. Injury treatment procedure Yes Meets Requirement 3
8. Rescue/evacuation procedures Yes Meets Requirement 3
9. Hazard recognition (JSA, HIRA, Protocols, Method statement etc) Yes Meets Requirement 3
[Link] substances Yes Meets Requirement 3
[Link]/excavation Yes Meets Requirement 3
[Link], barricades, flagging Yes Meets Requirement 3
13. Electrical safety Yes Meets Requirement 3
14. Rigging/crane safety Yes Meets Requirement 3
15. Confined Space entry and working Yes Meets Requirement 3
16. Welding/ Hotwork permit procedures Yes Meets Requirement 3
17. Synthetic fiber (Belt Slings & Similar items)handling procedures Yes Meets Requirement 3
18. Lockout/tag out procedures Yes Meets Requirement 3
19. Manual handling Yes Meets Requirement 3
20. Compressed gases/gas cylinders Yes Meets Requirement 3
21. Eye protection PPE Yes Meets Requirement 3
22. Hearing protection PPE Yes Meets Requirement 3
23. Foot protection PPE Yes Meets Requirement 3
24. Respiratory protection PPE Yes Meets Requirement 3
25. Chemical protective clothing Yes Meets Requirement 3
26. Fall-protection PPE Yes Meets Requirement 3
27. Hand protection PPE Yes Meets Requirement 3
28. Other – Please explain Yes Meets Requirement 3
When working on the following utility services, does your organization have and follow safe work procedures: (Electric supply, Gas lines,
B Yes Meets Requirement 3
Water supply or any other utility lines)
Provide evidence by showing copies of safe work procedures
Prior Exposure of contractor related to similar work environment / similar hazards (For BTG, BOP, Coal Handling, Ash Handling, Chimney,
C No Meets Requirement 0
working on sloped roof etc., - to be verified during the interview process)
Sub group total 87 5
4.11 Safety Inspections & Audits
A Does your organization have process to develop a site specific ‘Safety Inspection & audit Program’? Share a sample plan for evidence Yes Meets Requirement 3
Does your organization have process to systematically identify and record significant hazards in the place of work? Copies of Inspection program / Matrix,
B Yes Meets Requirement 3
Checklists etc., shall be demonstarted as evidence.
C Does your organization have a system in place to control the hazards? Yes Meets Requirement 3
D Does your organization have a system to advise JSW of any hazards, which will be introduced due to their scope of work? NA Meets Requirement
E Does your organization have a system to ensure the safety of visitor / other people working in the vicinity? NA Meets Requirement
F Do you have internal / external audit mechanism to ensure safety management system implementation at site? Yes Meets Requirement 3
Sub group total 12 4
4.12 Emergency preparedness and response
A Does your organization have emergency response procedures to deal with work-site emergencies? Yes Meets Requirement 3
B Will your organization have trained first-aiders on site who can respond in the event of an emergency? Provide copies of certificate Yes Meets Requirement 3
C Will your organization have trained fire-fighters (fire wardens) on site who can respond in the event of an emergency? Provide copies of certificate NA Meets Requirement
D Are you equipped to rescue personnel from height when they need to be evacuated / rescued from height? NA Meets Requirement
Number of first-aiders : 1 Number of fire Fighter (Fire Wardens):
Provide evidence by showing a copy of your emergency plan
Sub group total 6 2
Total Score 207
Total number of Not applicable criterion 9
PQA Score (%) 78%
Adjustment for Fatal incidents 2 -10%
Final PQA Score (%) 68%

5. Conditions
All Contractors, sub-contractors and their employees are expected to comply with JSW Occupational Health & Safety Policy.

Signed on and behalf of the contractor by:

Full name of the representative:
Signature:

Date:

6. JSW Evaluation
This section is to be completed by the JSW Representative to determine if the contractor should be accepted as an “Approved Contractor”

7.1 The assessment of the contractor is a: 7.2 Recommended as an “JSW Approved Contractor”
Pre-Qualification
Re-Qualification Contractor Category

Type of Work Approval: (Please mention the type or scope of work contractor is approved)

7.3 Authorisation
Having reviewed the information provided above and assessed the follow-up reports I acknowledge the Contractor’s suitability as an “Approved Contractor”:

Signed for and on behalf of JSW Ltd:

Name of PQ Team Leader:

(PQ team leader will be CSM chairman or a person designated by him)
Date:

Scoring Matrix

0 No No Evidence of system or process Yes and No Evidence cannot exist together Gap Analysis
1 Needs Improvement Informal process / system exist
1
3 Meets Requirement Formal System & Process exist
12 2
1
Negative marks for Fatal Incidents

If one incident (-5), two incident(-10), three incident (-15). More than 3 incidents in a year, qualification of contractors to be
decided by individual plants' CSM committee. This criteria is designed for Brownfield contractors can be revisited by individual 11 3
0.5
business conditions.

Summary of Scoring - Criteria wise - Calculate Manually and enter

Criterion % Score
Policies & Document 70% 10 0 4
Responsibilities 40%
Induction & Training 40%
Selection of sub-contractors 50%
Health Monitoring 60%
OH&S Recognition 60%
Plant & Equipment 70%
9 5
Accident / Incident Management 55%
PPE 55%
Occupational Health & Safety management system 50%
8 6
Safety Inspections & Audits 50%
Emergency preparedness and response 50% 7
Mandatory Requirements
PQA
#
Clause
1 4.1 B

2 4.3 A

3 4.3 C

4 4.3 G

5 4.6 B

6 4.7 A

7 4.8 A

8 4.9 C

9 4.11 B

10 4.12 A
Requirements

Questions

Does your organization have a Smoking, drug and alcohol policy?

Does your organization have a formal employee induction program? (Induction module to be
submitted to JSW)
Does your organization have a process to record job specific health, safety, environmental
training for employees? (submit training matrix as an evidence)
Does your organisation have safety communication program at client site?
1. Tool box talk
2. Self initiative of Mass Safety Communication / participation
3. Self Initiative of Various Safety Events and celebrations such as National safety day, World
Health day, etc., / participation
Do you have Safety Rewards & Recognition program at client site?
When using plant and equipment either owned by you or from any other party (leased,
hired, borrowed etc) do you have systems in place to ensure that,
1. All plant / equipment is fitted with safety devices as prescribed by legislation e.g. machine
guards
2. Plant and equipment fitness certificate as per legislation is available & Valid? (Ex:- Crane
test certificate, Earth moving equipment test certificate etc.,
3. Your employees have the correct licenses and/or certificates to operate the plant and
equipment?

4. Your employees who are to operate the plant and equipment are trained in its safe use?
Provide evidence of training records and licenses/certificates of above
Does your organization have an accident/incident reporting system?
Does the PPE provided comply with IS codes and any other legal requirements? Provide Test
certiicates / PO order

Does your organization have process to systematically identify and record significant hazards
in the place of work? Copies of Inspection program / Matrix, Checklists etc., shall be
demonstarted as evidence.
Does your organization have emergency response procedures to deal with work-site
emergencies?
Policies & Document
Responsibilities
Induction & Training
Selection of sub-contractors
Health Monitoring
OH&S Recognition
Plant & Equipment
Accident / Incident Management
PPE
Occupational Health & Safety management system
Safety Inspections & Audits
Emergency preparedness and response
80%
80% RADAR CHART
60%
70% Policies & Document
Emergency preparedness and response Responsibilities
80% 100%
80% Safety Inspections & Audits Induction & Training
65% 50%

70%
70% Occupational Health & Safety management system 0% Selection of sub-contractors

60%
80% PPE Health Monitoring
50%
Accident / Incident Management OH&S Recognition
Plant & Equipment