IM0702.5Gateway Site Access Accreditation Application for new Arqiva Subcontractors

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The completion of this application form and provision supporting documentation allows Arqiva to assess your application from a Safety, Health and Environmental perspective and to gather the required company information to allow your entry onto the Gateway Site Access System. The information required is dependant on the type of access being applied for:

1. Structure Including Rooftop structures & working on Poles / Earth Station at Height -Any activity which involves the climbing of a mast, tower, stub tower on a roof, a pylon, satellite earth station (including the dish, rear platform, wave guide or feed horn) or any similar structure.

2. Rooftop (Flat roof) - Any activity which involves work on a roof but not climbing a structure or pole on a rooftop.

3. Ground Other – Any activity which involves working within the site demise without working at height. E.g. grass cutting, trenching, fence repairs, etc.

4. Ground Cabin – An activity which involves working on building exteriors or inside an Arqiva building/Site Sharer’s equipment building/cabin. Where the cabin is on a rooftop this will be deemed rooftop work.

Each Accredited Access Company, and its employees, will be accredited to the appropriate level for the work you wish to carry out. All Accredited Access Company employees visiting a site to carry out activities in categories 1, 2 and 3 will be required to be registered on Gateway as Accredited Access Individuals (A separate accreditation application form must be completed) . The requirement for an Accredited Access Individual will not apply for any activity which is categorised as “4”.

All supporting documentation must be inserted into the application form in the appropriate places. The process for doing this may vary depending on the version of Word that is being used. However, the most common way to do this is as follows.

To Embed Files into this Application Form:

1. Place your mouse cursor where you want to insert the embedded file.

2. Click on the Insert pull down menu and then click on Object.

3. Click on the Create from file tab. 4. Click on Browse and locate the file

that you wish to embed.5. Click on the file and then click on

Insert.6. Select the Display as Icon check

box.7. Click on OK.

Please save the form as a Word document with your supporting documents embedded as PDF’s. All required information must be provided. If any information is missing, your application will be returned to you for amendment and must then be re-submitted.

Please note: If you intend to use sub-contractors to work on Arqiva sites, then these companies must be accredited in their own right. If you intend to undertake electrical works then you must also complete form IM1174.

Upon completion of the form, please email the electronic copy to accreditation@arqiva.com. For any queries please contact accreditation@arqiva.com, 01926 416895.

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By completing and submitting this form you are confirming that your organisation and employees comply with all applicable UK legislation including having applicable training, qualifications and competencies required to undertake the specified work activities.

SECTION 1: GENERAL INFORMATION

1.1 General Company Information

Company Name

Company Registered Address

Post Code

Tel No

Fax No

Other Company Locations (if applicable)

Number of Employees

Name of Person Completing this Form

Office Number

Mobile Number

Email Address

The Access Regulations Document located on the Arqiva web site requires all individuals on site to have visibility of an approved access document. Please read through the Access Regulations to gain an understanding of how the Gateway system will work. What process will you put in place in order to provide your employees with the Gateway Site Access Permits?

Where work involves an activity that Arqiva deems to be high risk due to the potential for damage to infrastructure, service interruption or personal injury, you must submit a construction phase health and safety plan / method

Please read SHE002 and the further information in the Supporting Information Guidance section at the end of this application form. Acknowledge in this box that you have done so and that your organisation understands

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statement and risk assessment for the work on Arqiva sites. The documents must be uploaded when you make your access request on Gateway.

The documentation must meet the minimum guidance specified in Arqiva document SHE002 which can be found on the Arqiva web site.

that it is the responsibility of the Requestors (persons raising Gateway access permit requests) to ensure your company RAMS meet Arqiva minimum requirements. I/We acknowledge the above requirements and confirm they will be adhered to:

Yes

No

(Delete as applicable)

What Level of Accreditation is Your Company Applying For? (delete as applicable)

Structure Including Rooftop Structures and Poles / Earth Station

Rooftop (Flat Roof Only)

Ground Other

Ground Cabin

Please confirm which Arqiva contractors you are/will be working on behalf of.

Please also provide details of the Arqiva projects and Arqiva project managers if known.

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1.2 Typical Work Activity

What typical work activities do you intend to carry out on Arqiva sites? For example, equipment installation, general maintenance, mast painting, wildlife monitoring etc.

Please provide as much information as possible as this will help us assess your application and level of risk more accurately.

How many Arqiva sites (approximately) do you intend to visit per year?

On average, how often do you think you will need to visit these sites?

Do you use Sub Contractors? (delete as applicable)

Yes

No

If you use sub contractors, please describe the work activities undertaken by these Sub Contractors and provide the names of the companies you use.

Please be aware that any subcontractors you intend to use must also have Site Access Accreditation, please acknowledge this (delete as applicable)

Yes, I acknowledge that any subcontractors I use should have Arqiva Accreditation in their own right.

No

If you use sub contractors, please describe the process your company uses to assess and monitor their competency. Please embed supporting documentation, such as procurement/H&S questionnaire.

Will you be transporting waste? (Only applicable if working for Arqiva)

Yes

No

If yes, please supply a copy of your Waste Carriers Licence.

Insert Waste Carriers Licence here

Will you be undertaking street works? If yes, please provide details of how you comply with the requirements of the New Roads and Street Works Act 1991 and provide evidence of applicable training.

Will you be using drones as part of your work activity? If yes, please provide evidence of how you comply with the regulations stated in Air Navigation Order 2016 (ANO 2016) and supply a copy of your current permission document from the Civil Aviation Authority (CAA)

1.3 Insurance

You are required to have Public Liability Insurance of at least £2million for any one claim. Please provide a copy of your current certificate in PDF format.

Insert your Public Liability Insurance Certificate here

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You are required to have Employee Liability Insurance. Please provide a copy of your current certificate in PDF format.

Insert your Employer/Employee Liability Insurance Certificate here.

1.4 Additional Supporting Information

If there is any additional general information that you would like to provide regarding your organisation, please include details here.

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SECTION 2: SAFETY, HEALTH & ENVIRONMENT (SHE) ASSESSMENTThis section requires you to provide both written answers and attachments of supporting documentation.

The type of information that you are required to provide depends on the level of accreditation you are applying for. It is clearly specified what is required and all parts of the appropriate section must be completed.

After completing Section 2.1, you should then complete the relevant table column in Section 2.2.

If you are carrying out any high risk activities please provide the relevant documents and information as specified in Section 2.3.

Guidance notes regarding the supporting information that we require for your application is included at the end of the application form. The guidance indicates the content and level of detail that we require for each element. You should use this guidance when completing Sections 2.2 and 2.3

Guidance is also available in the Safety Health and Environment section of the Arqiva web site

If you are unsure as to any aspect of the section you are required to complete, please contact a member of the Site Access Accreditation Team at accreditation@arqiva.com, 01926 416895.

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Section 2.1 General SHE Assessment2.1.1 Responsibilities

Health & SafetyWho in your organisation is responsible for Health & Safety?

Name:

Position:

Tel No:

Fax No:

Email:

What Health & Safety qualifications/experience do they have?

Are they an employee of your company or are they an external consultant? (delete as appropriate)

Employee

External Consultant

EnvironmentWho in your organisation is responsible for Environmental Management?

Name:

Position:

Tel No:

Fax No:

Email:

What Environmental qualifications/experience do they have?

Are they an employee of your company or are they an external consultant? (delete as appropriate)

Employee

External Consultant

2.1.2 Policies

Health & SafetyPlease provide a copy of your current Health & Safety Policy. It should contain the Policy Statement, Organisation and Arrangement details. It should also be signed and dated.

Note: If you have less than 5 employees you are not required to have a written policy,

Insert a copy of your full Health & Safety Policy here

EnvironmentPlease provide a copy of your current Environmental Policy. It should have evidence of review and should be signed and dated.

Note: If you have less than 5 employees you are not required to have a written policy,

Insert a copy of your Environmental Policy here

Section 2.1 General SHE Assessment (continued)2.1.3 Management Systems & External Accreditations

Health & SafetyHas your company implemented a Health & Safety Management system? (delete as applicable)

Yes

No

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If Yes, is it certified to OHSAS 18001, CHAS or UVDB Verify (Cat B1 or B2)? (delete as applicable)*

OHSAS 18001

CHAS

UVDB Verify B1 or B2

If Yes, please provide a copy of your certificate.

Insert a copy of your certificate here

EnvironmentHas your company implemented an Environmental Management system? (delete as applicable)

Yes

No

If Yes, is it certified to ISO 14001, CHAS or UVDB Verify (cat B1 or B2)? (delete as applicable)*

ISO 14001

CHAS

UVDB Verify B1 or B2

If Yes, please provide a copy of your certificate.

Insert a copy of your certificate here

UVDB Verify Certification*If your company has UVDB Verify Certification at Category B1 or B2, then please provide the following details:

UVDB Company Number

Member Level Category

Expiry Date

Health & Safety Scores MSE % Site %

Environment Scores MSE % Site %

*Notes:

ISO 14001 / OHSAS 18001 - If your company has achieved ISO 14001 and/or OHSAS 18001 certification, then Arqiva will accept this as partial evidence of your Health, Safety and/or Environmental compliance. Further guidance on this is included in the appropriate part of Section 2.2.

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Section 2.1 General SHE Assessment (continued)2.1.4 Prosecutions & Enforcements

Health & SafetyHas your company incurred any prosecutions, statutory enforcement or civil action with respect to health and safety during the last 5 years? (delete as applicable).

YesNo

If Yes, please provide details.

EnvironmentHas your company incurred any prosecutions, statutory enforcement or civil action with respect to the environment during the last 5 years? (delete as applicable).

YesNo

If Yes, please provide details.

2.1.5 Accident, Incident & Near Miss Reporting

Does your company investigate accidents, incidents and near misses? (delete as applicable)

Yes

No

If Yes, please provide a copy of your reporting and investigation process.

Insert a copy of your reporting and investigation process here

Has your company had any RIDDOR reportable incidents/accidents in the last 5 years? (delete as applicable)

Yes

No

If Yes, please provide details including type, event details and any preventative/corrective measures taken to prevent re-occurrence.Please provide your accident, incident and near miss statistics for the last 3 years, including:

Fatalities (RIDDOR) Major injuries (RIDDOR) Over 7 day injuries (RIDDOR) Minor injuries Accident Frequency Rate (AFR) Dangerous Occurrences Major Environmental Incidents Minor Environmental Incidents Near Misses

YYYY YYYY YYYYFatalities 0 0 0

Major Injuries 0 0 0

>7 Day Lost Time Injuries

0 0 0

Minor Injuries 0 0 0

AFR 0 0 0

Dangerous Occurrences

0 0 0

Major Environmental Incidents

0 0 0

Minor Environmental Incidents

0 0 0

Near Misses 0 0 0

2.1.6 Audits & Inspections (Monitoring of Workplaces)

Do you undertake audits and inspections of workplaces under your control and for activities undertaken by your employees/contractors? (delete as applicable)

YesNo

If yes, please provide a copy of your procedure and a sample audit or inspection report.

Please insert copy of your procedure and sample report here

Section 2.2 Application Specific SHE Assessment

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The level of accreditation you are applying for and what other certifications/accreditations you have, determines what additional supporting information we require. Use the table below to insert the required documentation for the appropriate level of access accreditation you are applying for:

Structure Including Rooftop Structures and Poles / Earth Station at

Height

Rooftop (Flat Roof Only)

Ground Cabin

Ground Other

Completed Risk Assessment & Method

StatementPlease insert your documents

here

Completed Risk Assessment & Method Statement

Please insert your documents here

Completed Risk Assessment & Method

StatementPlease insert your documents here

Completed Risk Assessment & Method

StatementPlease insert your documents here

Asbestos Control/Management

Please insert your document here. Document not required

if your company has OHSAS18001

Asbestos Control/Management

Please insert your document here. Document not required if

your company has OHSAS18001

Asbestos Control/Management

Please insert your document here. Document not required

if your company has OHSAS18001

Asbestos Control/Management

Please insert your document here. Document not required

if your company has OHSAS18001

Exposure to Non Ionising Radiation (RF) Policy & RF

Training Certificate Evidence

Please insert your document here

Exposure to Non Ionising Radiation (RF) Policy & RF

Training Certificate EvidencePlease insert your document

here

Roof Working Procedure/Policy

Please insert your document here

Roof Working Procedure/Policy

Please insert your document here

Working at Height Procedure/Policy

Please insert your document here

Working at Height Procedure/Policy

Please insert your document here

Working at Height Training Details/Certificates

Please insert your document here

Working at Height Training Details/Certificates

Please insert your document here

Rooftop Working Training Details/Certificates

Please insert your document here

Rooftop Working Training Details/Certificates

Please insert your document here

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Section 2.3 High Risk Activity Specific SHE AssessmentIf you are planning to carry out any of the following high risk activities or employing subcontractors who carry out these activities then please insert the required documents below. Refer to the Guidance section at the end of the form for more detail.

Electrical WorksWill you be undertaking electrical works? Yes/No (Delete as applicable)If yes, you must also complete and embed form IM1174 into this accreditation application for review.

Air conditioning systems, refrigerating systems, heat pumps or fire protection systemPlease insert your documents here, if this section doesn’t apply please add “N/A”

ExcavationPlease insert your documents here, if this section doesn’t apply please add “N/A”

Scaffolding (excluding scaffold towers)Please insert your documents here, if this section doesn’t apply please add “N/A”

Lifting steel work or dishes of 1.2m in diameter or largerPlease insert your documents here, if this section doesn’t apply please add “N/A”

Capstan, erection winchesPlease insert your documents here, if this section doesn’t apply please add “N/A”

Man riding winchesPlease insert your documents here, if this section doesn’t apply please add “N/A”

Hot worksPlease insert your documents here, if this section doesn’t apply please add “N/A”

CranesPlease insert your documents here, if this section doesn’t apply please add “N/A”

MEWPSPlease insert your documents here, if this section doesn’t apply please add “N/A”

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SECTION 3: FINANCIAL INFORMATION

FeesThe fee for company accreditation is £1,000 + VAT and is valid for two years.

The Fee is applicable to those who carry out a higher percentage of works on behalf of Third party operators and not Arqiva. Arqiva will not process this application until it is in receipt of the fee (If Required).

The fee for individual accreditation is £250 + VAT per person and is valid for two years. This fee applies for individuals requiring Ground, Rooftop, Structure or Earth Station at Height Accreditation and will only be considered upon the successful completion of company accreditation. All charges are subject to Arqiva Terms and Conditions and standard terms of payment, which are 30 days from the date of invoice.

Billing Address for one off fees (keys, supervision, engineer accreditations, etc):

Accounts Payable contact name, number and/or email:

Company Registration number:

VAT Number (if applicable):

Currency to be billed:

Please provide a sample of your Purchase Order Number Format i.e. A/09/12345

Purchase Order Number to quote on Invoice for Accreditation Fees (PO must be your own and not one issued by a Third Party)

Proposed Billing Amounts

Contract Signed (please delete as appropriate) YES NO

DECLARATION

Yes / No I acknowledge that I have read and understood the Arqiva Access Regulations. (These can be found here.)

Yes / No I acknowledge that whilst working on Arqiva sites, all applicable rules and guidance will be adhered to. (These can be found here.)

Yes / No I confirm that the information provided is accurate and I have not knowingly provided false information in support of the application.

Name

Date

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Supporting Information GuidanceUse the following notes as guidance on the level of detail that is required in the supporting documentation that you provide in Section 2.2 and 2.3. Not all documents are required for all levels of accreditation.

Section 2.2 Guidance

Method Statement & Risk AssessmentYou should provide a sample of a completed (not Generic) Method Statement and Risk Assessment for works that your company has previously undertaken. We require this to review your company’s ability to provide adequate documentation for the type of work that it is likely to undertake on Arqiva sites. The Health and Safety Executive website, www.hse.gov.uk can provide guidance on the 5 Steps to Risk Assessment.

Asbestos Control / ManagementWe would like evidence to confirm how your Company complies with the Control of Asbestos Regulations (2006) and how this is conveyed to your employees. This may impact differently on individual company’s dependent upon the type of work undertaken. We expect the level of reply to be in accordance with the level of risk associated with your company activities.

Exposure to Non-Ionising Radiation (RF) PolicyWe would like a copy of your RF Policy as evidence of how your company controls the presence of Non-Ionising Radiation. This should cover all forms of Non-Ionising radiation e.g. UV, Visible light, Radio Frequency, your employees are likely to encounter. Your policy should also include what its effects are and what preventative measures are utilised to control Non-Ionising Radiation. We expect the level of reply to be in accordance with the level of risk associated you’re your company’s activities.As a minimum your policy should cover the following key points:

What safety standards or guidelines are you working to? How does that work for you in practice? What are your default working limits? How do you manage any exceptions if you have any?

What RF Safety Awareness training do you provide to your staff? Who is providing it and what is the syllabus? (Note: to be acceptable for Arqiva, training should be at least half a day in duration but other companies may have different rules), what is the refresher period?

What type of personal monitors do you use? (Make and model), What thresholds do they alarm at?

What are the calibration arrangements? (How often? By whom? Who is responsible for ensuring the units are in calibration?)

What is your policy for monitor use (on Arqiva sites one per climber is the rule)

What do you expect people to do when their monitors alarm? Action to be taken, escalation routes?

If your company does RF safety surveys or RF safety measurements what type

If equipment is used for this (make and model and calibration arrangements), list of people who are approved RF surveyors? How is their competence assessed?

Action to be taken if RF over exposure is suspected

Screening procedure to identify people with implanted medical devices or other contra-indications for working with RF (in Arqiva this is done via the climbers medical)

Document review period

Roof Working and Working at Height ProceduresWorking at height and on roofs carries a high risk of accidents. In line with the Work at Height Regulations 2005, we require your company to advise us on what control measures are in place to manage the risk of working at height and on rooftops, including rescue procedures. We require evidence of any Rooftop Working and Working at Height Training that has been undertaken. Copies of certification will be required to be submitted in a PDF format.

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Roof Working, Working at Height (Mast Climbing/Rescue) and RF Training EvidenceWork at height and RF Awareness training is a mandatory requirement for rooftop and structure accreditation. If applying for either of these accreditation levels, you are required to include copies of training certificates as part of your application. Training certificates are only accepted from Arqiva Accepted Training Providers. A list of current accepted training providers and courses can be found here. Copies of certification will be required to be submitted in a PDF format.

Section 2.3 Guidance

Electrical WorkOnly competent personnel may work on electrical equipment and systems. All aspects of design, installation, commissioning, inspection, use and testing must conform to legal and technical standards, such as the Electricity at Work Regulations 1989 and the IEE Wiring Regulations We would like to see evidence of how you manage electrical safety within your organisation. Arqiva requires persons to hold a relevant ECS card as this in line with industry standards further information is available from Arqiva SHED if required. Form IM1174 must be completed and embedded in the application form if undertaking electrical works for Arqiva.

Air Conditioning Systems / Refrigerating Systems / Heat Pumps / Fire ProtectionWe would like to know how you comply with legislation and how you ensure training and competency in relation to The Fluorinated Greenhouse Gases Regulations 2008 and The Environmental Protection (controls on Ozone- Depleting Substances) Regulations 2002.

Excavation WorksWe would like to see how you meet the requirements of HSE guidance note HS(G)47 Avoidance of danger from underground services. A permit to dig system must be in place prior to any excavations commencing. Excavations must be adequately supported to prevent falls of material or earth, which may endanger any person. Where excavations are undertaken close to buildings or structures due regard must be taken of the additional loads imposed. Excavations must have suitable barriers and where appropriate lights and signs. Your documentation should cover these elements as a minimum.

Scaffolding (excluding scaffold towers)Scaffolding must be erected by competent persons and inspected before being brought into use and prior to every subsequent use. As a minimum, we would like to see what processes you have in place for ensuring competency of scaffold erection teams, what safe systems of work are in place for erection and dismantling and how you control hazards such as overhead lines, RF, falls from height, unauthorised access and preventing falling objectives. Inspection periods should also be documented.

Lifting Steel Work or Dishes of 1.2m in Diameter or LargerWe would like evidence as to what procedures/processes your company has in place for lifting steelwork/dishes of 1.2m in diameter or larger. As a minimum your documentation should include assessment of loads and lifting methods, assessment of weather conditions, communication methods during lifting/lowering, methods of rigging and avoiding damage to the structure.

Lifting/Lowering Using Capstan Winch / Erection WinchesWe would like evidence as to what procedures/processes your company has in place for using capstan winch and/or erection winches. As a minimum your documentation should include reference to anchor points, suspension of load in relation to operators, assessment of load and capacity of winch, and training/competency of operators

Using Man Riding WinchesWe would like evidence as to what procedures/processes your company has in place for using man riding winches. As a minimum, the documentation provided should include reference to musson fall arrest system, winch capacity, anchor points and training and competency requirements of winch operators.

Hot WorksNo activity involving hot work or naked flames may commence until a Permit to Work system has been implemented. We would like to see details of the type of hot works you carry out, how you control/manage the risks and what fire watch and emergency arrangements you put in place.

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Cranes and MEWPSWe would like you to provide details of your procedures relating to the use of Cranes and/or MEWPS. In relation to MEWPS, the information you provide should include, as a minimum, the training and competency requirements of the operator, inspection regimes, pre-use checks, adherence to HSE guidance, emergency/rescue procedures and control of risks. In relation to cranes, the information you provide should include, as a minimum, the training and competency requirements of the operator, inspection regimes, pre-use checks, emergency/rescue procedures, supervision details, lifting plans, slinging methods and control of risks.

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