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1、SUPPLIERAssessment QuestionnarieFACILITY DETAILSCompany Name:Site Name (if different):Parent Company Name (if applicable):Site Street Address:Site City:SiteState/Province/County:Site Postal/Zip Code:Site Country:SITE CONTACT INFORMATIONSite Representative Name (host):Title:Phone Number:Email Address
2、:HSE (Health, Safety, Environmental Protection) Representative Name:Title:HR (Human Resources) Representative Name:Title:Facility Background InformationPlease indicate which is the main activity of the siteFlood 口Volcanic Activity 口Is the facility located in a region that has experienced any of the
3、following natural disasters in the previous 50 years:Earthquake Tsunami Impact Damaging windstorm Hurricane/Typhoon Wildfires 口Tornado 口Primary language:Other languages (spoken by at least 10% of the workforce):If yes, what is the approximate number of workers living in company-provided housing:Desc
4、ribe the type of work currently being, orproposed to be performed at this facility (includeproduct types such as antibiotics, solvents):Please describe the facility HSE (Health Safety& Environment) resources (number of staff ortime spent on HSE):What is the primary language spoken by theIs company s
5、ponsored housing provided to anymajority of the employees at this location?contract or full time employees working at thislocation? Yes 口 No Number of Employees/Workers by Category (Provide data for the entire site. Also, please note that there may be workers/employees who fit into multiple categori
6、es and should be accounted for under each applicable category (i.e., there is overlap between categories)Total employee population onsite (including temporary, part-time and contract workers)Full time employees/workers directly employed by the companyPart-time employees/workers directly employed by
7、the companyIndirect, contract or dispatch employees/workersEmployees/workers under the age of 18Migrant or Foreign WorkersStudent workers (include students, apprentices and interns)Total Site Area (m2):Does your company own the facility?If the facility is not owned by the parent company, are the fol
8、lowing within your operational control?Indicate if the site is in a rural, industrial, residential or mixed commercial settingManufacturing Area (m 2):Yes DNo口If no, who owns the facility?Waste water treatment plant? Yes DNo Utilities? Yes DNo Security? Yes No Management of the roadways? Yes DNo Rur
9、al Industrial Residential 口Mixed commercial setting 口Please attach a local area map with water sources if available.When was this site initially constructed? Please indicate the years of industrial use of the site.No.QuestionAssessment NotesGeneral Health and Safety Management1.1Does your company ha
10、ve a written health and safety policy? Yes DNo N.A.1.2Has your company appointed a main board member with specific health and safety responsibility? If No or NA, explain Yes DNo N.A.Explain:1.3Does your company have a recognized health and safety certification, or have a plan to gain it? (OSHAS or a
11、nother standard).If yes and if you send a copy of the last certificate, it f Yes DNo N.A.1.4Does Your company have a documented risk management system as a part of the local HSE System? Yes DNo N.A.Explain:1.5Does your company have a risk assessment process to identify, prioritize, and mitigate the
12、potential HSE risks associated with your operations and activities? Yes DNo N.A.Explain:1.6Does your company conduct periodic audits of health safety practices at its operating facilities in order to assess conformance with regulatory and other requirements? Yes DNo N.A.Explain:1.8Does your company
13、Analyze the root causes of any identified accident, disaster, workplace disease and non conformity? Yes DNo N.A.Explain:No.QuestionAssessment NotesSafety/Health2.1Does your company have relevant EHS related education/training based on regulatory requirements (e.g. emergency, first aid,.) and records
14、 and kept? Yes DNo N.A.2.2Does your company provide protective equipment (e.g. hats, gloves, safety glasses, ear plugs) to workers exposed to chemical, biological and physical agents? Yes DNo N.A.2.3Does the site have systems for fire protection (Sprinklers, hydrants.) and fire prevention grounding/
15、bounding equipment, fire alarm, storage designed for flammable substances)? Yes DNo N.A.Explain:2.4Are first aid materials placed in convenient locations at the facility for immediate use? Yes DNo N.A.2.5Does the company perform risk-based medical monitoring or employee health surveillance? Yes DNo
16、N.A.2.6Does the company perform exposure monitoring for health and safety risks (vapors, noise levels, powder, pharmaceutical powders)? (explain which ones) Yes DNo N.A.Explain:2.7Does the company have a documented emergency response plan? Yes DNo N.A.2.8Does the company operates with your own fleet
17、 or is subcontracted? In case of subcontracted fill 2.9 Own Subcontracted2.9How many levels down does the third party logistics (3PL) allow its subcontractors to subcontract.Write the number or Explain:No.QuestionAssessment NotesEnvironment3.1Has your company appointed a main board member with speci
18、fic environmental responsibility? Yes DNo N.A.3.2Does your company have an environmental management system and/or plan to gain certification? (EMAS, ISO 14001 or other.) Yes DNo N.A.3.3Does your company have a program and/or procedures for management of wastewater? (Treatment, recycling.), If applie
19、s Yes DNo N.A.3.4Does your company have a program and/or procedure for management o solid waste, including collection, separation, disposal, and/or recycling? Yes DNo N.A.3.5Are your hazard substances stored in valid storage location within permitted quantities? If Applies Yes DNo N.A.3.6Does your c
20、ompany monitor your energy consumptions periodically (e.g. electricity, water, gas? Yes DNo N.A.3.7Does your company control the Carbon Footprint ? Yes DNo N.A.No.QuestionAssessment NotesLabor4.1Does your company/facility ensure that employment is freely chosen and that forced labor is never used? I
21、f no, explain Yes DNo N.A.Explain:4.2Does your company/facility ensure that recruitment and employment of workers is not misleading or fraudulent? If no, explain Yes DNo N.A.Explain:4.3Does the company ensure employment above the minimum legal employment age? If no, explain Yes DNo N.A.Explain:4.4Do
22、 all employees have an employee contract? If no, explain Yes DNo N.A.Explain:4.5Does your company/facility have a program to ensure that legal compensation (e.g. minimum wages, overtime hours .) is paid to all workers? If no, explain Yes DNo N.A.Explain:4.6Do your company/facility have a program for workers to communicate openly with management regarding working conditions? If no, explain Yes DNo N.A.Explain:4.7Does your company/facility have a program and/or procedures to ensure that the workplace is free of harsh and inhumane treatment? Yes DNo N.A.Explain: