CSHP Form 1A 2023 Application Form

NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP
Revised Form: CSHP Form 1A-2023:

Department of Labor and Employment APPLICATION FORM
REGIONAL OFFICE NO. ________ FOR THE EVALUATION/PROCESSING OF
CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Legal Bases: Type of Construction Project:

1. Presidential Decree No. 442, as renumbered _____DPWH project
2. Republic Act No. 11058
_____Other Public/private construction project
3. Department Order No. 198, Series of 2018
(LGUs, other gov’t offices, private entities)
_____ Residential project engaging the services of
a construction firm
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL CONTRACTOR/SUBCONTRACTOR/BUILDING OWNER in applying for a Construction Safety and Health
Program intended for a specific construction project.
Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with complete requirements and attachments will be processed.
A. Company Profile/License/Registration of Main/General Contractor
Complete Name of the Company/Main/ General Contractor/Project Complete Address of the Project
Owner Lot 5 & 7, Blk. 4, Springdale Garden Subdivision, Los Banos, Laguna
Vernoullis Industrial Corporation Tel. No: __________________________________________________
Fax No. ___________________________________________________
Name of Project Manager/Owner/ Contact Person: Tel. No: ___________________________________________________

Mr. Jonathan T. Ng Email: _____________________________________________________
Contractor’s PCAB/JV License No: Number of workers:

__________43874_________________ Male: __25_ Female: _____ Total employment: __25___
Date of Validity: April 12, 2025
Engaged Subcontractors’ Profile
Name of Sub-contractors (If any) Scope of Work and Project Cost No. of Workers PCAB License Date of Date of DOLE Registration
Validity
1.
2.
3.
4.
5.
6.
7.
(Use separate sheet, if necessary)
B. Project Profile/Description
Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or other documents indicating name and details of the project)
Two Storey Resort and Event Place
Complete Project Address/Location:

Lot 5 & 7, Blk. 4, Springdale Garden Subdivision, Los Banos, Laguna
Name of Project Owner: Tel. No: _____________

Mr. Jonathan T. Ng Fax No: _____________
Email : _____________
Project Classification: Estimated No. of Workers to be deployed in the Date of Estimated Start/Execution of the project:
Total Project Cost:__₱5,286,667.75___ project:

________25_________ ___March _/___01___/__2024_
(Workforce of the project to include workers of the Month Day Year
sub-contractor/s) Duration of the project (Pls. state the number of calendar days)
___________________________
Department of Labor and Employment APPLICATION FORM
REGIONAL OFFICE NO. ________ FOR THE EVALUATION/PROCESSING OF
PROGRAM (CSHP)
Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary)
Revised Form: CSHP Form 1A-2023 Page 2 of 3

Date of Revision: 30 April 2023
Department of labor and Employment

APPLICATION FORM
REGIONAL OFFICE NO. ______
FOR THE EVALUATION/PROCESSING OF
PROGRAM (CSHP)
OSH Personnel assigned to the project
Name Date of training Designated First Aider:
Elaiza L. Reyes 03/10-13/2020 Name Date of ID Validity
Eduardo C. Lagaras 08/24-28/2020 training
Designated Safety Officers: Marjon C. Alferez 11/06-07/2020
(Please attach photocopy of Certificate of Completion on the Basic OSH Course for Construction Site Safety Please attach a photocopy of the Certificate of First-Aid Training and valid First Aid ID from Phil Red
Officers issued by DOLE-BWC accredited Safety Training Organizations or recognized institution) Cross, DOH, Bureau of Fire and DOLE- Accredited TVIs with TESDA registered EMS and other
DOLE-Accredited first aid training provider
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of required 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:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
(Please attach additional sheet, if necessary.) (Attach photocopy of skills certification from TESDA.)
Profile of the person who prepared the CSH Program for the abovementioned Project
VERNIE T. BRIONES Educational Background:

Signature over printed name
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.
Submitted By:
ELAIZA L. REYES Project-in-Charge 06/11/2023
Signature Over Printed Name of the Owner/Contractor Position Date
Assigned Evaluator
I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON THE DOLE PRESCRIBED CHECKLIST.
Evaluated By:
Signature Over Printed Name Position Date

CSHP Form 1A 2023 Application Form

Uploaded by

Copyright:

Available Formats

CSHP Form 1A 2023 Application Form

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CSHP Form 1A 2023 Application Form

Uploaded by

Copyright:

Available Formats

NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

Revised Form: CSHP Form 1A-2023:

Legal Bases: Type of Construction Project:

_____ Residential project engaging the services of

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

Name of Project Manager/Owner/ Contact Person: Tel. No: ___________________________________________________

Contractor’s PCAB/JV License No: Number of workers:

Date of Validity: April 12, 2025

Engaged Subcontractors’ Profile

(Use separate sheet, if necessary)

Complete Project Address/Location:

Name of Project Owner: Tel. No: _____________

Total Project Cost:__₱5,286,667.75___ project:

Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary)

Revised Form: CSHP Form 1A-2023 Page 2 of 3

Department of labor and Employment

OSH Personnel assigned to the project

Name Date of training Designated First Aider:

Elaiza L. Reyes 03/10-13/2020 Name Date of ID Validity

Eduardo C. Lagaras 08/24-28/2020 training

Designated Safety Officers: Marjon C. Alferez 11/06-07/2020

Name Date of required BOSH Training

(If Heavy Equipment will be used in the Project)

VERNIE T. BRIONES Educational Background:

ELAIZA L. REYES Project-in-Charge 06/11/2023

Signature Over Printed Name of the Owner/Contractor Position Date

Signature Over Printed Name Position Date

You might also like

Total Project Cost:₱5,286,667.75_ project: