DOLE CSHP Form

Form Reference No: PM-NCR-03.
08-F-04
NO FEES REQUIRED FOR THE FILING , EVALAUTION AND APPROVAL OF CSHP

Revised Form.: CSHP-DO13-98:
Date of Revision : June1, 2011 Page 1of 3
REVISED APPLICATION FORM for

Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Legal Basis: Section 5 of Department Order No. 13 s 1998

(Guidelines Governing Occupational Safety and Health In Construction Industry)
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR in applying for an approval of a Construction Safety and Health Program intended for
a specific construction project.
Note: A CHECKLIST OF REQUIREMENTS shall be used in receiving the application.
Only an application form with a complete requirements and attachments will be processed.
Application found with incomplete requirements will be given 15 calendar days to comply. Failure to
comply within the prescribed period, the application will be deemed disapproved.
A. Company Profile/License/Registration of Main/General Contractor

Complete Name of the Company/ Complete Address:
Main /General Contractor
Tel. No:
Fax No.
Name of Project Manager/Contact Person: Email:
Main Contractor PCAB License Main Contractor Total employment _______

No.______________ ___ Male _____ Female _____
Date of Validity:_______________________
DOLE Registration of Main Contractor ( Pls. attach photo copy of Registration forms received and approved by
the concerned DOLE Regional Office)
Date Registered/Approved DOLE-RO
a. per DO 18-02 ( requires yearly renewal) __________________ __________
b. per Rule 1020, OSHS (one time registration) __________________ ___________

Sub-contractors’ Profile/License
No. of PCAB Validity Date of
Name of Sub-contractors (If , any) Scope of Work and Workers License Date DOLE
Project Cost Registration
1.
2.
3.
4.
5.
(Use separate sheet , if necessary)

REVISED APPLICATION FORM for
Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
B. Project Profile/Description
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the
project)
Complete Project Address/Location
Name of Project Owner

Tel. No: _____________
Fax No: _____________
Email : _____________
Project Classification: Date of Estimated Start/Execution of

Estimated No. of Workers to the project:
be deployed in the project: ________________________
Month Day Year
___________________
Duration of the project (Pls.
Total Project Cost:__________________ (Workforce of the project to state the number of calendar days
include workers of the sub-
contractor/s) _________________________
Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)
Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011 Page 2of 3
Department of labor and Employment APPLICATION FORM for APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY AND HEALTH PROGRAM
OSH Personnel assigned to the project
Name of Appointed Safety Officer/s: Name of Appointed First-Aider/s:
____________________________________ ______________________________________
Date of his/her BOSH training: _________________ Date of First –Aid Training: _______________
(Pls. attach photo copy of Certificate of Completion on the Validity of ID: __________________
Basic OSH Course for Construction Site Safety Officers issued
by DOLE-BWC accredited Safety Training Organizations or (Pls. attach photo copy of Certificate of First-Aid Training
recognized institutions) and Valid First Aider ID from PNRC
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of BOSH Training
OH Nurse
OH Physician
Dentist
(If Heavy Equipment will be used in the Project)

List of Heavy Equipment to be Used in the Project Name of Heavy Equipment Operator/s (To attach photo
(Please attach additional sheet, if necessary) copy of skills certification from TESDA)
Profile of the person who prepared the CSH Program for the abovementioned Project:
Name and Signature Educational Background:
___________________________ Work Experience in OSH:

Signature over printed name
Other Qualifications:
I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULLNESS OF THE ABOVEMENTIONED

INFORMATION. THE COMPANY HEREBY COMMIT TO STRICTLY IMPLEMENT THE ATTACHED
CONSTRUCTION SAFETY and HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.
Submitted By:
Signature Over Printed Name ______________________________________
Position: ______________________________________________________
Date: ______________________________________________________
Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011 Page 3 of 3

DOLE CSHP Form

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Form Reference No: PM-NCR-03.

NO FEES REQUIRED FOR THE FILING , EVALAUTION AND APPROVAL OF CSHP

REVISED APPLICATION FORM for

Legal Basis: Section 5 of Department Order No. 13 s 1998

Note: A CHECKLIST OF REQUIREMENTS shall be used in receiving the application.

A. Company Profile/License/Registration of Main/General Contractor

Main Contractor PCAB License Main Contractor Total employment _______

b. per Rule 1020, OSHS (one time registration) __________________ ___________

(Use separate sheet , if necessary)

Complete Project Address/Location

Name of Project Owner

Fax No: _____________

Project Classification: Date of Estimated Start/Execution of

Revised Form.: CSHP-DO 13-98

OSH Personnel assigned to the project

Name of Appointed Safety Officer/s: Name of Appointed First-Aider/s:

(If Heavy Equipment will be used in the Project)

___________________________ Work Experience in OSH:

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULLNESS OF THE ABOVEMENTIONED

Signature Over Printed Name ______________________________________

Revised Form.: CSHP-DO 13-98

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b. per Rule 1020, OSHS (one time registration) ________ _