application form for osh consultant › images › files › info materials... · original...

TO BE ACCOMPLISHED IN DUPLICATE This form is NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH-C-N

APPLICATION FORM FOR OSH CONSULTANT (NEW) of 4

INSTRUCTIONS: Please attach your

1” X 1” Picture 2 COPIES

Signed at the back

1. Fill in all the data needed. 2. Use BLOCK/PRINTED letters or use a TYPEWRITER. 3. Write N/A if the blanks are Not Applicable. 4. Please sign in all pages of the form.

PERSONAL PROFILE

TITLE FIRST NAME MIDDLENAME LASTNAME

City Address (Number & Street, Town/City, Province, Zip Code) Home Tel. No.

Mobile No.

E-mail

PRC License No.

Home/ Provincial Address Date of Birth Sex

Citizenship Civil Status

COMPANY PROFILE

Business Address E-mail Address Co. Tel. No. Region

Website Fax No. Zip Code

Nature of Business Employment Size

Male Female Total

Type of Service

Workplace

Specific Product Hazardous Non-Hazardous

WORK EXPERIENCE (Use additional sheet if necessary). Please attach original certificate of employment and job description duly certified by the Personnel Manager/employer/ or authorized company official using official company letter head; and proof of practice (safety report/programs prepared/implemented)

Total OSH EXPERIENCE

Position (From Recent to Present Inclusive Dates Length of

Service Status of

Appointment Company

From To




DOCUMENTARY REQUIREMENTS REMARKS

1. Two (2) copies of duly accomplished Application Form (OSH-C-N) with 2 copies most recent 1 x 1 ID picture signed at the back (blue background).

2. Original Certificate of Employment indicating name, position and date of appointment at present position using the official letterhead of the company.

3. Original of actual Duties and Responsibilities at present position, signed by immediate supervisor and Personnel Manager or authorized official of the company, using letterhead of the company

4. Photocopy of certificate of employment from previous employer/s indicating position(s) and date(s) of appointment (if any and necessary in support of actual experience on OSH). May submit list of actual functions and proof of accomplishments, duly certified by the employer.

5. Photocopy of certificate of completion of the DOLE prescribed advance course (80-hr) on Occupational Safety and Health issued by accredited STO.

6. Photocopy of certificate of attendance/participation on other OSH related trainings/seminars/activities.

7. Photocopy of College Diploma or Transcript of Records and Board Exam Certificate or PRC License (if any).

8. Submission of summarized OSH trainings with a total of at least 480 hours. Attach photocopy of certificates (Refer to table below for format)

Table

Title Issued by Inclusive Dates

9. Proof/s of accomplishment or participation in OSH ____ Accident reports _____ Safety inspection/audit reports ____ HSC committee report _____ OSH program prepared/

implemented 10. Other reports prepared by the applicant please specify ______

OSH RELATED LECTURES/TRAININGS/SEMINARS ATTENDED - As Resource Speaker (Use additional sheet if necessary). Please attach photocopy of certificate/recognition received.

Title/Topic (From recent to previous)

Time/Duration No. of Hours

Conducted by Venue




OSH SKILLS/EXPERTISE/SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

Trade/Occupation Field of Expertise Brief Description Years of Experience

OSH AWARDS/ACHIEVEMENTS/RECOGNITION RECEIVED (Use additional sheet if necessary) Please attach photocopy of certificate of award/recognition.

Title Issued by Date Issued

OSH EXAMINATIONS/ELIGIBILITIES PASSED (If any). Use additional sheet if necessary). Please attach photocopy of ID, license or certification.

Title Year Taken Given by Rating

MEMBERSHIPS/AFFILIATIONS RELATED TO OSH

Organization/Institution/Agency Designation Validity




CHARACTER REFERENCES (Give at least 3)

Name Address Contact No. E-mail Address

Do you have any pending administrative case? (Yes/No) If YES, please give details.

Do you have any pending criminal case? (Yes/No) If YES, please give details.

Have you ever convicted of any administrative offense?(Yes/No) If YES, please give details.

Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or tribunal? (Yes/No) If YES, please give details.

Have you ever been retired, forced to resign or dropped from employment in the public and/or private sector? (Yes/No) If YES, please give reasons.

I certify that the information stated above is true and correct.

SIGNATURE DATE


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH-C-R

APPLICATION FORM FOR OSH CONSULTANT (RENEWAL) Page 1 of 4

INSTRUCTIONS: Please attach your

1” X 1” Picture 2 COPIES

Signed at the back

Accreditation NO.: __________________ Date of First Accreditation:_______________ Date of Last renewal:_________________ Validity:___________________________

1. Fill in all the data needed. 2. Use BLOCK/PRINTED letters or use a TYPEWRITER. 3. Write N/A if the blanks are Not Applicable. 4. Please sign in all pages of the form.

PERSONAL PROFILE

TITLE FIRST NAME MIDDLENAME LASTNAME

City Address (Number & Street, Town/City, Province, Zip Code) Home Tel. No.

Mobile No.

E-mail

PRC License No.

Home/ Provincial Address Date of Birth Sex

Citizenship Civil Status

COMPANY PROFILE

Business Address E-mail Address Co. Tel. No. Region

Website Fax No. Zip Code

Nature of Business Employment Size

Male Female Total

Type of Service

Workplace

Specific Product Hazardous Non-Hazardous

WORK EXPERIENCE (Use additional sheet if necessary). Please attach original certificate of employment and job description duly certified by the Personnel Manager/employer/ or authorized company official using official company letter head; and proof of practice (safety report/programs prepared/implemented)

Total Years of OSH Experience

Position (From Recent to Present Inclusive Dates Length of

Service Status of

Appointment Company

From To




DOCUMENTARY REQUIREMENTS

REMARKS

Two (2) copies of duly accomplished Application Form (OSH-C-R) with 2 copies most recent 1 x 1 ID picture signed at the back (blue background).

Summary of Applicant’s Accomplishments as OSH Consultant signed by the employer or supervisor using official letterhead of the company.

Proof/s of accomplishment or participation in OSH: ____ Accident reports _____ Safety inspection/audit reports ____ HSC committee report ____ _OSH program prepared/ implemented ____ Other reports prepared by the applicant please specify ______

Photocopy of Certificate of Accreditation (last issued)

Photocopy of other OSH related trainings/seminar attended as participant after last renewal of accreditation- at least 16 hours per year or 48 hours of trainings for 3 years, earned from DOLE recognized/accredited STO/institutions authorized by law.

When There is a Change of Employer/Position:

Original Certificate of Employment indicating name, position and date of appointment at present position, using official letterhead of the company.

Original Certificate of actual Duties and Responsibilities at present position, using official letterhead of the company, signed by immediate supervisor and Personnel Manager or authorized official of the company.

INITIAL EVALUATION/REMARKS Complete documents submitted, signed in all pages With incomplete documents, for compliance of the above stated deficiencies with mark “X”. For interview on _________ at _____, please call ______________________ Others, specify _________________

Submission of summarized OSH trainings attended as participant. Attach

photocopy of certificates ( Refer to table below for format)

Table

Title Issued by Inclusive Dates




OSH RELATED LECTURES/TRAININGS/SEMINARS ATTENDED - As Resource Speaker (Use additional sheet if necessary). Please attach photocopy of certificate/recognition received.

Title/Topic (From recent to previous)

Time/Duration No. of Hours

Conducted by Venue

OSH SKILLS/EXPERTISE/SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

Trade/Occupation Field of Expertise Brief Description Years of Experience

OSH AWARDS/ACHIEVEMENTS/RECOGNITION RECEIVED (Use additional sheet if necessary) Please attach photocopy of certificate of award/recognition.

Title Issued by Date Issued

OSH EXAMINATIONS/ELIGIBILITIES PASSED (If any).

Use additional sheet if necessary). Please attach photocopy of ID, license or certification.

Title Year Taken Given by Rating

MEMBERSHIPS/AFFILIATIONS RELATED TO OSH

Organization/Institution/Agency Designation Validity




CHARACTER REFERENCES (Give at least 3)

Name Address Contact No. E-mail Address

Do you have any pending administrative case? (Yes/No) If YES, please give details.

Do you have any pending criminal case? (Yes/No) If YES, please give details.

Have you ever convicted of any administrative offense? (Yes/No) If YES, please give details.

Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or tribunal? (Yes/No) If YES, please give details.

Have you ever been retired, forced to resign or dropped from employment in the public and/or private sector? (Yes/No) If YES, please give reasons.

I certify that the information stated above are true and correct. SIGNATURE DATE

TO BE ACCOMPLISHED IN DUPLICATE This form is NOT FOR SALE and maybe REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH–CO-N

APPLICATION FORM FOR OSH CONSULTING ORGANIZATION - NEW Page 1 of 2

INSTRUCTION

Please accomplish completely and attach the required documents. Refer to checklist of requirements listed below for attachments new and mark in the left portion all documents submitted.

Pursuant to requirement of D.O. 16, series 2001, We would like to apply for an accreditation as SAFETY CONSULTING ORGANIZATION

Name of Organization Company Address

Name of Top Company Head Official Title/Designation

Telephone No. Fax No. Employment Size Male Female Total

TIN No. E-mail Address Website

(This COLUMN is to be accomplished by

OSHC)

CHECKLIST OF REQUIREMENTS REMARKS

1. Duly accomplished application form.

2. Certified true copy of Business Registration with SEC or DTI whichever is applicable

3. Certified true copy of Mayor’s Permit/License to operate.

4. Certified true copy of Registration with DOLE Regional Office.

5. Certified true copy of Registration with BIR.

6. Contract of Agreement with Consultant/Resource Person with valid accreditation.

7. Resume of Consultants and copy of Certificate of Accreditation.

Received by: (Signature over printed name)

Evaluator’s Remark

Position:

Region: Date/Time:


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH–CO-N

APPLICATION FORM FOR OSH CONSULTING ORGANIZATION - NEW Page 2 of 2

Staff – Please attach your organizational chart

Name of Administrative/ Support Staff

Position Educational Background Type of Employment

(Regular, Project Based, Contractual)

If contractual (specify period of contract)

Technical – Use additional sheet if necessary. Please attach resume of technical staff/resource speakers and contract of

agreements with them.

Name of Technical Staff Highest Educational

Attainment Field of expertise/specialization/

competence

If accredited as OSH Professional, specify

Accreditation No. and Validity

Office Facilities, Equipment and Material and Office Personnel REMARKS

A. Office is located in suitable location having a business-like environment accessible to means of public transportation and with proper identification.

B. Has at least 3 office tables and chairs. C. Office has sufficient space to move around comfortably. With at least 25 sq. Meter. D. Lighting and ventilations are adequate. E. Has at least one set of each of the following items: Telephone, fax machine and other suitable

communication equipment.

F. Has at least one set of working computer and printer. G. Has one regular staff available to answer telephone calls and queries during office hours. H. Has a person authorized to issue company decisions. I. Receiving area has at least 1 table and chairs for staff & clients. J. Meeting or briefing room can accommodate at least 6 persons. K. Files and equipment are properly stored, labelled and well secured. L. There is suitable storage area/place for equipment and records. M. Has at least one regular subscription to safety and health related materials. N. Maintains an updated library of safety and health materials, books, standards and related materials. O. Has equipment/materials necessary for the type of OSH consultancy services. P. Has clean and sanitized comfort room.

Type of OSH Consultancy – Please attach list of available equipment necessary in the conduct of type of OSH consultancy, services, provided. Attach also list of clients (if any)

Type of Services Provided

OSH Safety Program Development and Implementation Fire Prevention, Protection and Control Risk Assessment

OSH Safety Audit/Evaluation Work Environment Measurement

Occupational Safety Management System Work Accident Investigation

In-Plant Safety Inspection Other, Please specify

I certify that the information stated above are true and correct.

SIGNATURE DATE


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH–CO-R

APPLICATION FORM FOR OSH CONSULTING ORGANIZATION - RENEWAL Page 1 of 2

INSTRUCTION


Pursuant to requirement of D.O. 16, series 2001, We would like to apply of the renewal of accreditation as SAFETY CONSULTING ORGANIZATION

Accreditation No.: Name of Organization

Date of First Accreditation:

Date of Last Renewal: Company Address

Validity:




(This COLUMN is to be accomplished by OSHC)



9. Certified true copy of Business Registration with SEC or DTI whichever is applicable.





14. Resume of Consultants and copy of Certificate of Accreditation.



Position:

Region: Date/Time:


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH–CO-R

APPLICATION FORM FOR OSH CONSULTING ORGANIZATION - RENEWAL Page 2 of 2










competence




Q. Office is located in suitable location having a business-like environment accessible to means of public transportation and with proper identification.

R. Has at least 3 office tables and chairs S. Office has sufficient space to move around comfortably. With at least 25 sq. Meter. T. Lighting and ventilations are adequate. U. Has at least one set of each of the following items: Telephone, fax machine and other suitable


V. Has at least one set of working computer and printer. W. Has one regular staff available to answer telephone calls and queries during office hours. X. Has a person authorized to issue company decisions. Y. Receiving area has at least 1 table and chairs for staff & clients. Z. Meeting or briefing room can accommodate at least 6 persons. AA. Files and equipment are properly stored, labelled and well secured. BB. There is suitable storage area/place for equipment and records. CC. Has at least one regular subscription to safety and health related materials. DD. Maintains an updated library of safety and health materials, books, standards and related materials. EE. Has equipment/materials necessary for the type of OSH consultancy services. FF. Has clean and sanitized comfort room.

Type of OSH Consultancy – Please attach list of available equipment necessary in the conduct of type of OSH consultancy, services, provided. Attach also list of clients (if any)

Type of Services Provided

OSH Safety Program Development and Implementation Fire Prevention, Protection and Control Risk Assessment

OSH Safety Audit/Evaluation Work Environment Measurement

Occupational Safety Management System Work Accident Investigation

In-Plant Safety Inspection Other, Please specify


SIGNATURE DATE


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH-STO-N

APPLICATION FORM FOR OSH TRAINING ORGANIZATION - NEW Page 1 of 2

INSTRUCTION


Pursuant to requirement of D.O. 16, series 2001, We would like to apply for an accreditation as SAFETY TRAINING ORGANIZATION

Name of Organization Company Address











20. Contract of Agreement with Consultant/Resource Person with valid accreditation

21. Contract of Agreement with training venue (for applicant without training venue)

22. Resume of Consultant/Resource Person and copy of Certificates of Accreditation and Trainers’ Training



Position:

Region: Date/Time:


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH-STO-N

APPLICATION FORM FOR OSH TRAINING ORGANIZATION - NEW Page 2 of 2










competence




GG. Office is located in suitable location having a business-like environment accessible to means of public transportation and with proper identification

HH. Has at least 3 office tables and chairs. II. Office has sufficient space to move around comfortably. With at least 25 sq. Meter. JJ. Lighting and ventilations are adequate. KK. Has at least one set of each of the following items: Telephone, fax machine and other suitable


LL. Has at least one set of working computer and printer. MM. Has one regular staff available to answer telephone calls and queries during office hours. NN. Has a person authorized to issue company decisions. OO. Receiving area has at least 1 table and chairs for staff & clients. PP. Meeting or briefing room can accommodate at least 6 persons. QQ. Files and equipment are properly stored, labelled and well secured. RR. There is suitable storage area/place for equipment and records. SS. Has at least one regular subscription to safety and health related materials. TT. Maintains an updated library of safety and health materials, books, standards and related materials. UU. Has equipment/materials necessary for the type of OSH trainings provided (e.g. LCD projector,

laptop/computer, sample PPE).

VV. Has clean and sanitized comfort room.


SIGNATURE DATE


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH-STO-R

APPLICATION FORM FOR OSH TRAINING ORGANIZATION - RENEWAL Page 1 of 2

INSTRUCTION


Pursuant to requirement of D.O. 16, series 2001, We would like to apply of the renewal of accreditation as SAFETY TRAINING ORGANIZATION

Accreditation No.: Name of Organization

Date of First Accreditation:

Date of Last Renewal: Company Address

Validity:












29. Resume of Consultant/Resource Person and copy of Certificate of Accreditation.



Position:

Region: Date/Time:


DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center OSH-STO-R

APPLICATION FORM FOR OSH TRAINING ORGANIZATION - RENEWAL

Page 2 of 2










competence




WW. Office is located in suitable location having a business-like environment accessible to means of public transportation and with proper identification.

XX. Has at least 3 office tables and chairs. YY. Office has sufficient space to move around comfortably. With at least 25 sq. Meter. ZZ. Lighting and ventilations are adequate. AAA. Has at least one set of each of the following items: Telephone, fax machine and other suitable


BBB.Has at least one set of working computer and printer. CCC. Has one regular staff available to answer telephone calls and queries during office hours. DDD. Has a person authorized to issue company decisions. EEE. Receiving area has at least 1 table and chairs for staff & clients. FFF. Meeting or briefing room can accommodate at least 6 persons. GGG. Files and equipment are properly stored, labelled and well secured. HHH. There is suitable storage area/place for equipment and records. III. Has at least one regular subscription to safety and health related materials. JJJ. Maintains an updated library of safety and health materials, books, standards and related materials. KKK. Has equipment/materials necessary for the type of OSH trainings provided (e.g. LCD projector,

laptop/computer, sample PPE).

LLL. Has clean and sanitized comfort room.


SIGNATURE DATE

DEPARTMENT OF LABOR AND EMPLOYMENT Occupational Safety and Health Center

DOLE –OSHC-STO-Tr

NOTICE of Conduct of OSH TRAINING

Approved by:

MA. TERESITA S. CUCUECO, M.D. Executive Director Date :

Training Organization:

Accreditation No.: Validity:

Address:

Contact Person:

May we request for the approval on the conduct of OSH Training specified below.

Title of Training and Specific Topic Inclusive Dates and Venues Name & Signature of Assigned Resource Speaker

Name and Signature Date

Date: Dear Director Teresita S. Cucueco: Please be informed of the following changes in the conduct of the abovementioned training as specified below:

( ) new schedule/date ( ) new venue ( ) new/additional speakers Title of OSH Training New Schedule/Date of

Training New Venue of Training Name of New/Additional Speakers with

their signature

Name and Signature of Authorized Official

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