NO FEES REQUIRED FOR THE FILING, EVALUATION AND APPROVAL OF CSHP

Revised Form.: CSHP-DO13-98:

Date of Revision: June 1, 2011

Page 1of 3

Department of Labor and Employment

REGIONAL OFFICE NO. ____

Legal Basis:

REVISED APPLICATION FORM for

EVALUATION/APPROVAL OF
CONSTRUCTION SAFETY AND
HEALTH PROGRAM (CSHP)

Section 5 of Department Order No. 13 s 1998

(Guidelines Governing Occupational Safety and Health In Construction Industry)

Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR in applying for an approval of a Construction Safety and Health Program intended for
a specific construction project.
Note: A CHECKLIST OF REQUIREMENTS shall be used in receiving the application.
Only application form with complete requirements and attachment will be processed. Application found
with incomplete requirements will be given 15 calendar days to comply. Failure to comply within the
prescribed period, the application will be deemed disapproved.
A. Company Profile/License/Registration of Main/General Contractor
Complete Address:
Complete Name of the Company/
Main /General Contractor
Tel. No:
Fax No.
Name of Project Manager/Contact Person:
Main Contractor PCAB License
No. _______________
Date of Validity:
________________________

Email:

Main Contractor Total employment

Male

Female

DOLE Registration of Main Contractor ( Pls. attach photo copy of Registration forms received and approved by
the concerned DOLE Regional Office)
Date Registered/Approved
DOLE-RO
a.

per DO 18-02 ( requires yearly renewal)

b.

per Rule 1020, OSHS (one time registration)

Sub-Contractors Profile/License
Name of Sub-contractors
(If , any)

1.
2.
3.
4.
5.
(Use separate sheet , if necessary)

Scope of Work and

Project Cost

No. of
Workers

PCAB
License

Validity
Date

Date of
DOLE
Registration

Department of Labor and Employment

REGIONAL OFFICE NO. ____

REVISED APPLICATION FORM for

EVALUATION/APPROVAL OF
CONSTRUCTION SAFETY AND
HEALTH PROGRAM (CSHP)

B. Project Profile/License/Description
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the
project)

Complete Project Address/Location

Name of Project Owner

Tel. No:
Fax No:
Email :

Project Classification:

Estimated No. of Workers to

be deployed in the project:

Date of Estimated Start/Execution of

the project:

Month

Total Project Cost:

(Workforce of the project to
include workers of the
subcontractor/s)

Day

Year

Duration of the project (Pls. state the

number of calendar days)

Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)

Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011

Page 2of 3

Department of labor and Employment

REGIONAL OFFICE NO. ______

APPLICATION FORM for APPROVAL OF

CONSTRUCTION SAFETY AND HEALTH PROGRAM

OSH Personnel assigned to the project

Name of Appointed Safety Officer/s:

Name of Appointed First-Aider/s:

Date of his/her BOSH training:

Date of FirstAid Training:

(Pls. attach photo copy of Certificate of Completion on

the Basic OSH Course for Construction Site Safety
Officers issued by DOLE-BWC accredited Safety
Training Organizations or recognized institutions)

Validity of ID:
(Pls. attach photo copy of Certificate of First-Aid
Training and Valid First Aider ID from PNRC

Other OH personnel (if more than 50 workers will be deployed in the project)
Name
Date of BOSH Training
OH Nurse
OH Physician
Dentist

(If Heavy Equipment will be used in the Project)

List of Heavy Equipment to be Used in the Project
(Please attach additional sheet, if necessary)

Name of Heavy Equipment Operator/s (To attach

photo copy of skills certification from TESDA)

Profile of the person who prepared the CSH Program for the abovementioned Project:
Name and Signature

Educational Background:
Work Experience in OSH:

Signature over printed name

Other Qualifications:

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULLNESS OF THE ABOVEMENTIONED

INFORMATION.
THE COMPANY HEREBY COMMIT TO STRICTLY IMPLEMENT THE ATTACHED
CONSTRUCTION SAFETY AND HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.
HEREBY
Submitted By:
Signature Over Printed Name
Position:
Date:
Page 3 of 3

Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

BUREAU OF WORKING CONDITIONS (BWC)
APPROVAL OF CONSTRUCTION SAFETY AND HEALTH PROGRAM
CHECKLIST OF REQUIREMENTS FOR SUBMISSION TO THE BWC
Completed / Submitted
Yes No
Remarks
A. General Requirements
a. Two (2) copies of letter of intent
b. Name of authorized contact person with telephone number/s
c. Two (2) copies of the Safety and Health Program. One copy must be original
print.
B. CSH Program must contain the following:
1. Name of person who prepared the program
(Please indicate if accredited by DOLE as OSH Practitioner)
2. Project Description
a. Specific name of project
b. Location of the project
c. Project classification
d. Project owner
e. Name of main contractor
f. Estimated number of workers to be deployed
g. Estimated start of execution of project
h. Estimated duration
3. Company Safety Policy written on a company letterhead.
Must be duly signed by the highest company official or the highest-ranking
company representative who has over-all control of project execution.
4. Management/Owners Commitment to comply safety and health policy
5. Composition of Safety and Health Committee (per project)
Must specify the proposed structure and membership of the safety and health
committee (Specify the names)

6. Names of the safety and health personnel (depending on the number of

7.

workers to be deployed on the construction site)

Specific duties and responsibilities of the Safety Officer

SPECIFIC PROVISIONS ON THE FOLLOWING (if applicable)

8. On-site safety and health promotion and continuing information

9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

dissemination
Accident and incident investigation and reporting
Protection of the general public within the vicinity and the vicinity of the
construction site
Environmental control
Guarding of hazardous machinery
Personal Protective Equipment
Handling of Hazardous substances
General materials handling and storage procedures
Workers skills and certification (for critical occupation)
Provisions for transportation facilities for workers in case of emergency
Temporary Fire Protection Facilities and equipment

19. First aid and health care medicines, equipment and facilities

Completed / Submitted

Yes No
20. Workers Welfare Facilities
21. Proposed Hours of Work and Rest Breaks
22. Construction Waste Disposal

23. Testing and Inspection of construction heavy equipment (if construction

heavy equipment will be utilized in the project per requirements of Sec.10,
D.O. No. 13)
24. Disaster and Emergency Preparedness contingency plan

25. Standards Operating Procedures and Job Hazard Analysis for the
following activities and other hazardous work not outlined herein.
a. Site Clearing
b. Excavation
c. Erection and Dismantling of scaffolds and other temporary platforms
d. Temporary electrical connections/installations
e. Use of scaffolds and other temporary working platforms
f. Working at unprotected elevated working platforms
g. Use of power tools and equipment
h. Gas and electric welding and cutting operations
i. Working in confined spaces
j. Use of internal combustion engines
k. Handling hazardous and / or toxic chemical substances
l. Use of hand tools
m. Use of mechanized lifting appliances for movement of materials
n. Use of construction heavy equipment
o. Demolition
p. Installation, use and dismantling of hoist and elevators
26. Penalties/sanctions for violation of the provision/s of the SH Program
C. ATTACHMENTS
1. Photocopy of Registration Forms received and approved by the concerned
DOLE Regional Office.
- Per D.O. 18-02 (Require yearly renewal)
- Per Rule 1020 of the OSHS (one time Registration)
2. Photocopy of invitation to Bid / Project Contract
3. Photocopy of Certificate of Completion on required Training of all designated
OSH Personnel
- Safety Officer Basic Occupational Safety and Health Training for
Construction Site Safety Officer
- OH Nurse Basic Occupational Safety and Health Training for OH Nurse
(if any)
- First Aider Standard First Aid Training and valid PNRC ID as First Aider
- OH Physician Basic Course on Occupational Medicine (if any)
4. Certificate of Inspection and Testing of Construction Heavy Equipment by
organization accredited by DOLE (if any)
5. Skills Certificate of Construction Heavy Equipment operators issued by
TESDA (if any)
6. Contract with nearby hospital / clinic in lieu of the required infirmary hospital.
7. In case your previous application for safety program has not been awarded,
please attach certificate from the bid-tendering agency that you were not
awarded the previous program for the project where health and safety officers
and first aiders were assigned.

Remarks