Asia South SBU – CHESM Interim and Post-Job Evaluation Form
1. General Contractor Company Name: Contract/Project Name or Number: Chevron Contract Owner: Number of employees supporting the contract/operations: Company Director/Manager: Contractor Key Personnel: Phone: Email/Fax:
Site Supervisor: Phone: Email/Fax:
HES Representative: Phone: Email/ Fax:
Evaluation Completed by: Name: Position: Phone: Email/Fax Date Submitted:
2. HES Performance Data
Provide HES performance data specific to the Chevron Year _____ Year _____ Year _____ project/contract, not to exceed 3 years Total number of employee hours worked Number of work-related fatalities Number of injuries that resulted in restricted work
activity Number of injuries that resulted in one or more days
away from work
Number of injuries and illnesses involving medical
treatment
Number of motor vehicle accidents
Version 1.0.1 July 1st 2007. 1 Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc Asia South SBU – CHESM Interim and Post-Job Evaluation Form
2. HES Performance Data
Provide HES performance data specific to the Chevron Year _____ Year _____ Year _____ project/contract, not to exceed 3 years Number of oil and chemical spills
Annual percent (%) employee turnover rate Have you received any regulatory citation or been involved in any Yes No court litigation in the last three years?
3. HES Management Systems Improvement Acceptable Comments Needed HES Performance
1. Safety/Health performance
2. Environmental performance
3. Significant events
4. Annual percent (%) employee turnover rate
5. Regulatory or court litigation
HES Management
1. HES organization
2. Employee benefits
3. HES targets
4. HES written programs
5. Employee engagement
6. Safety meetings
7. Subcontractor management
8. Inspections and audits
9. Hazard identification and control
10. Incident investigation and reporting
11. Incident corrective action
2 Version 1.0.1 Revised 1st July 2007. Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc Asia South SBU – CHESM Interim and Post-Job Evaluation Form
3. HES Management Systems Improvement Acceptable Comments Needed
12. Sharing of incident learning
13. Behavior-based safety
14. Personal protective equipment
15. Regulatory compliance
16. Pollution prevention
17. Emergency preparedness
Fitness for Duty: Skills, Knowledge and Training
1. Short -service employees
2. Craft training
3. HES orientation
4. HES training (content)
5. Training records
Fitness for Duty (Medical and Industrial Hygiene)
1. Medical services
2. Medical examinations
3. Substance abuse N/A
4. Industrial hygiene N/A
Equipment and Materials 1. General 2. Equipment
Version 1.0. 1 Revised 1st July 2007. 3 Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc Asia South SBU – CHESM Interim and Post-Job Evaluation Form
4. Action Items Needs Improvement/Not Acceptable Corrective Action Required Target Actual Subject Date Completion
6.
7.
8.
9.
10.
Attach additional sheet if needed.
Contract Owner: Date reviewed with Contract Owner:
Corrective actions to be completed by: Contract firm informed Yes No Name informed: Date: of results? Contract firm to remain on re-selection bid list? Yes No Date:
4 Version 1.0.1 Revised 1st July 2007. Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc