Entity Submission Form - Form C

FORM C
SUBMISSION OF EHSMS DOCUMENTS
FOR REVIEW AND APPROVAL
General Information
Name of Entity:
Registration Number :
Classification Code:
Number of Employees:
Percentage of time engaged
in office based activities:
Percentage of time engaged in
on-site / field based activities:
EHSMS Development:
Developed by Internal EHS
Resources
Name of Internal Manager Leading
EHSMS Development:
Developed by EHS Consultancy:
Name:
EC Number:
Date(s) of EHSMS
Document Submission:
First Submission Date
__ __ (Day) __ __ (Month) __ __ __ __ (Year)
Subsequent Submission Date __ __ (Day) __ __ (Month) __ __ __ __ (Year(
Subsequent Submission Number _______________
EHSMS Information
EHS Requirements:
Please list the title (and reference number) of the
document that addresses the EHSMS requirements.
1.0 Submittals and Report Organization
1.1 Includes document version, history and completed Form C
1.2 Cleary defined document structure - easy to navigate
2.0 EHS Policy
2.1 Integrated Environment, Health and Safety Policy
2.2 Signed by Top Management
2.3 Evidence of communication to all stakeholders
2.4 Commits to providing adequate resources
2.5
Includes reference to Sector EHS Policy and/or AD Emirate
EHS Policy.
3.0 EHS Management System
3.1 Defines scope of the EHSMS
3.2 Defines roles and responsibilities - specific to entity
3.3 Evidence of clear communication of EHS Roles
3.4 EHS impacts review of all products, activities and services
3.5
Document structure clear, including document control, record
retention and change management procedures
4.0 Targets and Objectives
4.1
Establishes EHS Targets and Objectives - linked to Sector /
AD EHSMS KPI's
4.2 Responsibilities assigned to specific individuals
4.3 Action plan, including timeframes, developed
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FORM C
SUBMISSION OF EHSMS DOCUMENTS
FOR REVIEW AND APPROVAL
5.0 Legal Compliance
5.1 Legal compliance procedure developed
5.2 Identifies legislation specific to entity (eg Legal Register)
5.3 Identifies review procedure
5.4 Identifies compliance requirements - entity specific
6.0 Risk Management
6.1 A clear risk management procedure developed
6.2 Includes entity specific roles and responsibilities
6.3 Hazard and Risk quantification matrix included
6.4
Effective review incorporated, including process of change
within the entity
6.5 Top management involvement
6.6 Workforce involvement
6.7 Hazard Management Program in place for all identified risks
6.8 Specifies control measures, considers ALARP
6.9 Entity specific risk assessments undertaken
7.0 Contractor Management
7.1 Clear procedure developed
7.2 Defines roles and responsibilities - specific to entity
7.3 Incorporates the "Management of Contractors Process"
7.4 Includes monitoring of performance
7.5
Includes specific "construction work" processes and
responsibilities
8.0 Emergency Management
8.1 Clear procedure / plan developed
8.2 Entity specific
8.3
Includes entity specific escalation and communication
procedures (Internal and External)
8.4
8.5
Identifies specific situations that will be classified as an
emergency
Includes business contingency plans for emergency
situations - specific to entity
9.0 Specific Entity Standard Operating Procedures
9.1 SOP's developed for high/medium risk activities
9.2
9.3
Incorporates control measures indentified in risk
management activities
Indentifies and incorporates AD EHSMS RF / Sector
operational requirements
9.4 Clear communication / consultation and training to workforce
10.0 Training and Competency
10.1 Clear procedure developed
10.2 Entity specific training needs analysis completed
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FORM C
SUBMISSION OF EHSMS DOCUMENTS
FOR REVIEW AND APPROVAL
10.3 Entity specific training matrix completed
10.4
Role/Job Descriptions developed (including EHS
requirements and competencies)
11.0 Hazard, Near Miss and Incident Reporting and Investigation
11.1
Clear procedure developed, incorporating the Sector / AD
EHSMS RF requirements for reporting
11.2 Includes entity specific internal reporting
11.3 Clear responsibilities for top management to review
11.4
11.5
Clear process for near miss and hazard reporting within the
entity
Investigation procedures include all requirements set by the
Sector / AD EHSMS RF
12.0 Communication and Consultation
12.1
Clear procedure developed, incorporating the Sector / AD
EHSMS RF requirements
12.2 Worker involvement (named positions / individuals)
12.3 Structure of internal EHS meetings / activities
12.4
Process to consult with relevant internal / external
stakeholders (specific to entity)
13.0 Audit and Inspection
13.1
Clear procedure developed, incorporating the Sector / AD
EHSMS RF requirements
13.2 Defines roles and responsibilities - specific to entity
13.3
Internal and external requirement, includes annual 3rd party
compliance audit
13.4 Includes Audit and Inspection requirements
13.5
Includes Audit and Inspection requirements includes the
entities supply chain
13.6 Non conformance and corrective action management
13.7 Includes senior management review
14.0 EHS Performance Monitoring and Reporting
14.1
14.2
Clear procedure developed, incorporating the Sector / AD
EHSMS RF requirements
Internal and external reporting hierarchies - Specific to the
entity
14.3 Includes Sector / AD EHSMS RF requirements and KPI's
14.4 Includes top management review
14.5 Annual performance report development
15.0 Management Review
15.1
Clear procedure developed, incorporating the Sector / AD
EHSMS RF requirements
15.2 Management review team identified - specific to entity
15.3 Review and meeting schedules
15.4 Terms of reference for review meetings
15.5 Clear roles and responsibilities assigned
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FORM C
SUBMISSION OF EHSMS DOCUMENTS
FOR REVIEW AND APPROVAL
* Please attach all EHSMS documents being submitted with this form.
Declaration
I declare that all information provided in this document is true, correct and complete.
Signature of the
Authorised
Contact Person:
Official
Stamp:
Date :
_____/_____/_____
Approval of EHSMS as Submitted by Entity:
Yes
No, reasons / amendments required:
Official Use
___________________________________________________________________________________________
Date for resubmission of EHSMS for Review and Approval: (If Applicable)
Not Required
__ __ (Day) __ __ (Month) __ __ __ __ (Year)
Required date for commencing the implementation of EHSMS: __ __ (Day) __ __ (Month) __ __ __ __ (Year)
Note: EHS Performance and Incident Reporting Requirements commence from this date.
Note: Annual Third Party External Compliance Audit must be undertaken with (12) Twelve months from this date.
Date Entity Notified of Decision: __ __ (Day) __ __ (Month) __ __ __ __ (Year)
Evaluation of EHSMS Form Completed and Submitted to Competent Authority (AD EHSMS Form I)
Yes
Relevant Authority Stamp
Entered into Database by:
Name:
Signature:
Date:
_____ / _____ / _____
Reviewed by:
Name:
Signature:
Date:
_____ / _____ / _____
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