NO FEES REQUARED FOR THE FILLING , EVALUATION AND APPROVAL OF CSHP

Revised Form : CSHP-DO13-98:

Date of Revision: June 1, 2011 Page 1 of 4

REVISED APPLICATION FORM for

Department of Labor and Employment EVALUATION /APPROVAL OF
REGIONAL OFFICE NO. 3 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)

Instruction: 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 complete requirements shall attachments will be processed.
Application found with incomplete requirements will be given 15 calendar days to comply. Failure to comply
within the prescribed, the application will be deemed disapproved.

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

Complete Name of the Company/
Complete Address: 5143/5234 Sitio Maugot, San Isidro,
Main/General Contractor
San Marcelino, Zambales
RAIK CONSTRUCTION AND SUPPLY Tel. No:
Fax No:
Name of Project Manager/Contact Person: Email:
CRISTOPHER RAGADIO GONGORA
Main Contractor PCAB License Main Contractor total Employment 20 .

No. 40660 .

20 Male Female .

Date of Validity: June 30, 2018 .

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) February 15, 2016 Olongapo City .

Sub-contractors’ Profile/License
Date of
Scope of Works and No. of PCAB Validity
Name of Sub-contractors (If , any) DOLE
Project Cost Workers License Date
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. 3 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)

Project ID NO. 18CM0006 – CONSTRUCTION OF MULTI-PURPOSE BUILDING MAPASIG-

PASIG ELEMENTARY SCHOOL (COVERED COURT)

Complete Project Address/Location

Batiawan, Subic, Zambales

Name of Project Owner

Tel. No: ____________
Department of Public Works and Highways
2nd District Engineering Office
Fax No: ____________
Castillejos, Zambales

Email : _____________

Project Classification:
Estimated No. of Workers to Date of Estimated
be deployed in the project: Start/Execution of the project:
GB1 – Building Construction
20 February 12, 2018 .

Month Day Year

.

Scope of Work:

New Construction (Workforce of the project to

include workers of the sub-
Total Project Cost: contractor/s) Duration of the project (Pls. state
the number of calendar days
Php 1,916,405.67 90 Calendar Day

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

 Other General Requirements

- Project Billboard/Signboard
- Occupational Safety and Health Program
- Mobilization/Demobilization (including Hauling of Debris)

 Earthworks
- Structure Excavation (Column Footing, Footing Tie Beam and Pedestal)
- Fill and Backfill
- Gravel Bedding (Column Footing and Footing Tie Beam)

 Concrete Works
- Reinforced Concrete (Column Footing, Footing Tie Beam and Pedestal)
- Reinforcing Steel, Grade 40
- Forms and Falseworks

 Roof Framing and Roofing Works

- Structural Steel (Furnished, Fabricated and Elected)
- Prepainted Metal Sheets, Rib Type

Revised Form : CSHP-DO13-98:

Date of Revision: June 1, 2011 Page 2 of 4
 CONSTRUCTION WORK FLOW BY SCHEDULE
Contract ID 18CM0006
Contract Name CONSTRUCTION OF MULTI-PURPOSE BUILDING MAPASIG-PASIG ELEMENTARY
SCHOOL (COVERED COURT)
Contract Location Batiawan ,Subic, Zambales

90 CALENDAR DAYS
MANPOWER
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Other General Requirements
Earthworks
Concrete Works
Roof Framing and Roofing Works

Revised Form : CSHP-DO13-98:

Date of Revision: June 1, 2011 Page 3 of 4
 Department of Labor and Employment APPLICATION FORM for APPROVAL OF
REGIONAL OFFICE NO. 3 CONSTRUCTION SAFETY AND HEALTH PROGRAM

OSH Personal assigned to the project

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

CRISTOPHER RAGADIO GONGORA . RONALD DE GUZMAN TIZON ..

Date of First - Aid Training: January 15-18, 2018

Date of his/her BOSH training: October 11-15, 2011
.

(pls. attach photo copy of Certificate of Completion on the Validity of ID: January 18, 2020 ..

Basic OSH Course for Construction Site Safety Officers Issued ( (Pls. attach photo copy of Certificate of First-Aid
by DOLE-BWC accredited Safety Training Organizations or
Training and Valid First Aider ID from PNRC
recognized institution)

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 CRISTOPHER RAGADIO GONGORA .

Position : OWNER/MANAGER .

Date : .

Revised Form : CSHP-DO13-98:

Date of Revision: June 1, 2011 Page 4 of 4
 JOB HAZARD ANALYSIS
Contract ID 18CM0006
Contract Name CONSTRUCTION OF MULTI-PURPOSE BUILDING MAPASIG-PASIG ELEMENTARY
SCHOOL (COVERED COURT)
Contract Location Batiawan ,Subic, Zambales

ITE RISK
M ACTIVITY HAZARDS ASPECT CONSEQUENCES CATEGOR SAFETY CONTROLS
NO. Y
1 - Construction of - Excavation collapse - Personnel injury L - Toolbox Meeting
Earthworks - Compliance of PPE
2 - Construction of - Repeated - Discomfort L - Shorten the Exposure / even
steel works movements / manual - Personnel injury distribution of workplace
lifting
3 - Concrete Pouring - Workers are engage - Face/eye injury H - Toolbox Meeting
on working with with bouncing - Compliance of PPE
Concrete Mixer crush - Personnel In-Charge of the
- Personnel injury work are certified and fully
aware of the job safety
4 - Pulling of Steel - Workers are engage - Falling Object H - Toolbox Meeting
- Construction of on working with Crane - Personnel injury - Compliance of PPE
Roof and Framing - Elevated works - Inhalation of - Safety Harness
Works - Chemical hazards chemicals (Smoke - Personnel In-Charge of the
of Welding) work are certified and fully
aware of the job safety
5 - Construction of - Chemical Hazards - Inhalation of H - Toolbox Meeting
Painting and - Electrical Hazards chemicals (Paint - Compliance of PPE (Face
Electrical Works - Elevated works materials) Mask)
- Electric Shock - Lock-out Tag-out System
- Personnel In-Charge of the
work are certified and fully
aware of the job safety
- Provision of PPE (High
voltage gloves)