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

Direct Administration / To be implemented by project owner

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

Project Province Location

Name of Project Owner

Email Address

Telephone Number

Mobile Number

Project Classification

Total Project Cost

Project is a Government Project

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 Activities / 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 Work Schedule

Profile of person who prepared the CSH Program for the project

Full Name

Educational Background

Work Experience in OSH

Other Qualifications

C.Client Feedback Survey

Type of Client Served

General Public

Business/Private Company

Government Agency/Official/Employee

Pesta(Date)

Kasarian (Gender)

Email Adddress

Pangalan(Name)

Edad(Age)

Contact Number

Cizitens Charter Questions

CC1 Do you know about the Citizen’s Charter (document of an agency’s services and reqs.)?

Yes, aware before my transaction with this office
(Oo, alam ko bago ang aking transaksyon sa opisinang ito)

Yes, but aware only when I saw the CC of this office
(Oo, pero alam ko lang nung nakita ko yung CC nitong opisina)

No, not aware of the CC (Skip questions CC2 and CC3)
(Hindi, hindi ko alam ang CC (Laktawan ang mga tanong CC2 at CC3) )

CC2 If Yes to the previous question, did you see this office’s Citizen’s Charter? (Kung Oo sa nakaraang tanong, nakita mo ba ang Citizen’s Charter sa opisinang ito?)

Yes, the CC was easy to find
(Oo, madaling mahanap ang CC)

Yes, but the CC was hard to find
(Oo, ngunit ang CC ay mahirap hanapin)

No, I did not see this office’s CC (Skip question CC3)
(Hindi, hindi ko nakita ang CC ng opisinang ito (Laktawan ang tanong CC3)

CC3 If Yes to the previous question, did you use the Citizen’s Charter as a guide for the service/s you availed?

Yes, I was able to use the CC
(Oo, nagamit ko ang CC)

No, I was not able to use the CC because
(Hindi, hindi ko nagamit ang CC dahil)

Pakilagyan ng tsek (✓) ang kahon na nagsasaad ng iyong tugon. (Please put a check mark (✓) in the appropriate box corresponding to your response.)
Mga Detalye (Particulars)	Lubos na nasiyahan (Very Satisfied) 😀 5	Nasiyahan (Satisfied) 🙂 4	Ni nasiyahan o hindi nasiyahan (Neither Satisfied nor Dissatisfied) 🤔 3	Hindi nasiyahan (Dissatisfied) 😕 2	Lubos na hindi nasiyahan (Very Dissatisfied) 😠 1
0. I am satisfied with the service that I availed. ((Ako ay kontento sa serbisyo na aking napakinabangan)
1. I spent an acceptable amount of time to complete my transaction (Gumugol ako ng katanggap-tanggap na tagal ng oras upang makumpleto ang aking transaksyon) (Responsiveness)
2. The office accurately informed and followed the transaction’s requirements and steps (Ang opisina ay may wastong kaalaman at sinunod ang mga kinakailangan at hakbang ng transaksyon ) (Reliability)
3. My online transaction (including steps and payment) was simple and convenient (Ang aking online na transaksyon (kabilang ang mga hakbang at pagbabayad) ay simple at maginhawa) (Access and Facilities)
4. I easily found information about my transaction from the office or its website (Madali kong nahanap ang impormasyon tungkol sa aking transaksyon mula sa opisina o sa website nito) (Communication)
5. I paid an acceptable amount of fees for my transaction (Nagbayad ako ng katanggap-tanggap na halaga ng mga bayarin para sa aking transaksyon) (Costs)	NOT APPLICABLE
6. I am confident my online transaction was secure (Ako ay tiwala na ang aking online na transaksyon ay naging matiwasay) (Integrity)
7. The office's online support was available, or (if asked questions) online support was quick to respond (Available ang online na suporta ng opisina, o (kung magtatanong) mabilis na tumugon ang online na suporta) (Assurance)
8. I got what I needed from the government office. (Nakuha ko ang kailangan ko sa opisina ng gobyerno.) (Outcome)
Reklamo sa serbisyong natanggap mula sa DOLE (Complaint on the service provided by DOLE):	Mungkahi/Rekomendasyon upang mas mapaganda pa namin ang pangkalahatang Serbisyong naibigay (Suggestion/ Recommendation on how we could improve our overall service):

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.

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:

I hereby certify on my honor to the truthfulness of the abovementioned information. The company hereby commits to strictly implement the attached Construction Safety and Health Program designed for the abovementioned project.