DOLE-RO5 | Construction Safety and Health Program

A. Company Profile / License / Registration of Main or General Contractors

Name of Company / General Contractor

Street Address

Region

Province

City/Municipality

Barangay

Telephone Number

Cellphone Number

Name of Owner/ Project Manager/ Contact Person

Email Address

Male Workers

Female Workers

PCAB License Number

PCAB Validity Date

PCAB Certificate Copy

DO 174 Number

DO 174 Date Registered / Approved

Issued By:

DO 174 Registration

Rule 1020 Registration Number

Rule 1020 Date Registered / Approved

Issued By

Rule 1020 Certificate

Sub-contractors' Profile/License

B. Project Profile / Description

Name of Project Owner

Email Address

Telephone Number

Mobile Number

Project Classification

Total Project Cost

Estimated No. of Workers including subcontractors

Date of Start / Execution of Project

Duration of Project In days

Letter of Intent

Signed Construction Safety and Health Program (Comprehensive) File Click here for a copy of the CSHP Template

Brief Description of Actiities / Work Flow

C. OSH Personnel assigned to the project

Other OSH Personnel (if more than 50 workers will be deployed in the project)

OH Nurse

Name of Nurse

Date of BOSH Training

OH Physician

Name of Physician

Date of BOSH Training

Dentist

Name of Dentist

Date of BOSH Training

Upload Certificate of Employment of Safety Officer and First Aider Click here for the template

Upload Construction Work Site Schedule (if there is only one set of Safety Officer and First Aider

Profile of person who prepared the CSH Program for the project

Full Name

Educational Background

Work Experience in OSH

Other Qualifications

Letter of Approval from DPWH

Notice of Award

Company Profile/License/Registration of Main/General Contractor

Name of Company / General:
Company Address:
Region:
Province:
City / Municipality:
Barangay:
Telephone Number:
Contact Number:
Email Address:
Main Contractor Details
Name of Project Manager/Contact Person:
Main Contractor PCAB License No.:
PCAB License Date Validity:

Sub-contractors’ Profile/License

Project Profile / Description

Name of Owner:
Telephone Number:
Contact Number:
Email Address:
Project Classification:
Total Project Cost:
Estimated No. of Workers including subcontractors:
Date of Start / Execution of Project:
Duration of Project In calendar Days:
Brief Description of Actiities / Work Flow:

OSH Personnel

Safety Officers
No.	Name of Safety Officer	Date of Training

First Aiders
No.	Name of First Aider	Date of Training	Validity of ID

Other OH personnel
Name		Date of BOSH Training
OH Nurse
OH Physician
Dentist

Heavy Equipments
No.	Name of Heavy Equipment	Name of Operator

Profile of person who prepared the CSH Program for the project
Full Name:
Educational Background:
Work Experience in OSH:
Other Qualifications:

Profile of person who prepared the CSH Program for the project
DPWH Letter of Approval File Uploaded:

I hereby certify that all the information provided by me in this application are true and correct to the best of my knowledge. I understand that all the information I provided will form part of the public record, which may be used for any legal processes of the government. Thus, any misrepresentation of facts may subject my application to denial and myself to possible administrative and/or criminal action. I also do understand that incomplete applications would be subject for denial.