SUPPLIER

AssessmentQuestionnarie

FACILITYDETAILS

CompanyName:

SiteName(ifdifferent):

ParentCompanyName(if

applicable):

SiteStreetAddress:

Site

SiteCity:

State/Province/County:

SitePostal/ZipCode:SiteCountry:

SITECONTACTINFORMATION

SiteRepresentativeName

Title:

(host):

PhoneNumber:EmailAddress:

HSE(Health,Safety,

EnvironmentalProtection)Title:

RepresentativeName:

HR(HumanResources)

Title:

RepresentativeName:

FacilityBackgroundInformation

Pleaseindicatewhichisthemainactivityofthe

site

Flood□VolcanicActivity口

IsthefacilitylocatedinaregionthathasEarthquake□TsunamiImpact□

experiencedanyofthefollowingnatural

disastersintheprevious50years:Damagingwindstorm口Hurricane/Typhoon□

Wildfires□Tornado□

Describethetypeofworkcurrentlybeing,or

proposedtobeperformedatthisfacility(include

producttypessuchasantibiotics,solvents):

PleasedescribethefacilityHSE(HealthSafety

&Environment)resources(numberofstaffor

timespentonHSE):

WhatistheprimarylanguagespokenbytheIscompanysponsoredhousingprovidedtoany

majorityoftheemployeesatthislocation?contractorfulltimeemployeesworkingatthis

location?YesDNo□

Primarylanguage:

Otherlanguages(spokenbyatleast10%ofthe

workforce):Ifyes,whatistheapproximatenumberofworkers

livingincompany-providedhousing:

NumberofEmployees/WorkersbyCategory(Providedatafortheentiresite.Also,please

notethattheremaybeworkers/employeeswhofitintomultiplecategoriesandshouldbe

accountedforundereachapplicablecategory(i.e.,thereisoverlapbetweencategories)

Totalemployeepopulationonsite(including

temporary,part-timeandcontractworkers)

Fulllimeemployees/workersdirectlyemployed

by(hecompany

Part-timeemployees/workersdirectlyemployed

bythecompany

Indirect,contractordispatchemployees/workers

Employees/workersundertheageof18

MigrantorForeignWorkers

No.QuestionAssessmentNotes

GeneralHealthandSafetyManagement

Doesyourcompanyhaveawrittenhealthand□YesDNo

1.1

safetypolicy?□N.A.

□YesDNo

Hasyourcompanyappointedamainboard

1.2□N.A.

memberwithspecifichealthandsafety

responsibility?IfNoorN.A,explainExplain:

Doesyourcompanyhavearecognizedhealth

andsafetycertification,orhaveaplantogain

□YesQNo

it?(OSHASoranotherstandard).

1.3

Ifyesandifyousendacopyofthelast□N.A.

certificate,it'snotnecessaiytoanswerthe

questions1.4-1.9

DoesYourcompanyhaveadocumentedrisk□YesQNo

1.4managementsystemasapartofthelocalHSE□N.A.

System?Explain:

Doesyourcompanyhaveariskassessment□YesDNo

1.5processtoidentify,prioritize,andmitigatethe□N.A.

potentialHSErisksassociatedwithyourExplain:

operationsandactivities?

Doesyourcompanyconductperiodicauditsof

□Yes□No

healthsafetypracticesatitsoperatingfacilities

1.6□N.A.

inordertoassessconformancewithregulatory

andotherrequirements?Explain:

DoesyourcompanyAnalyzetherootcauses□YesDNo

1.8ofanyidentifiedaccident,disaster,workplace□N.A.

diseaseandnonconformity?Explain:

No.QuestionAssessmentNotes

Safcty/Health

DoesyourcompanyhaverelevantEHSrelated

education/trainingbasedonregulatory□YesDNo

2.1requirements(e.g.emergency,firstaid,...)□N.A.

andrecordsandkept?

Doesyourcompanyprovideprotective

□YesDNo

equipment(e.g.hats,gloves,safetyglasses,

2.2□N.A.

earplugs)toworkersexposedtochemical,

biologicalandphysicalagents?

Doesthesitehavesystemsforfireprotection

□YesQNo

(Sprinklers,hydrants...)andfireprevention

2.3□N.A.

grounding/boundingequipment,firealarm,

storagedesignedforflammablesubstances)?Explain:

□YesDNo

Arefirstaidmaterialsplacedinconvenient

2.4□N.A.

locationsatthefacilityforimmediateuse?

□YesONo

Doesthecompanyperformrisk-basedmedical

2.5□N.A.

monitoringoremployeehealthsurveillance?

Doesthecompanyperformexposure

□YesDNo

monitoringforhealthandsafetyrisks(vapors,

2.6□N.A.

noiselevels,powder,pharmaceutical

powders)?(explainwhichones)Explain:

□YesDNo

Docsthecompanyhaveadocumented

2.7□N.A.

emergencyresponseplan?

Docsthecompanyoperateswithyourown

□Own□Subcontracted

2.8fleetorissubcontracted?Incaseof

subcontractedfill2.9

Howmanylevelsdowndoesthethirdparty

2.9

logistics(3PL)allowitssubcontractorstoWritethenumberorExplain:

subcontract.

No.QuestionAssessmentNotes

Environment

Hasyourcompanyappointedamainboard□YesDNo

memberwithspecificenvironmental□N.A.

3.1

responsibility?

Doesyourcompanyhaveanenvironmental□YesDNo

managementsystemand/orplantogain□N.A.

3.2

certification?(EMAS,ISO14001orother...)

Doesyourcompanyhaveaprogramand/or□YesDNo

3.3proceduresformanagementofwastewater?□N.A.

(Treatment,recycling...).Ifapplies

Doesyourcompanyhaveaprogramand/or

UYesUNo

procedureformanagementosolidwaste,

□N.A.

3.4includingcollection,separation,disposal,

and/orrecycling?

Areyourhazardsubstancesstoredinvalid□YesDNo

3.5storagelocationwithinpermittedquantities?If□N.A.

Applies

Docsyourcompanymonitoryourenergy□YesDNo

3.6consumptionsperiodically(e.g.electricity,□N.A.

water,gas?

□YesDNo

DoesyourcompanycontroltheCarbon

3.7□N.A.

Footprint?

No.QuestionAssessmentNotes

Labor

□YesDNo

Doesyourcompany/facilityensurethat□N.A.

4.1employmentisfreelychosenandthatforcedExplain:

laborisneverused?Ifno,explain

Doesyourcompany/facilityensurethat□YesDNo

4.2recruitmentandemploymentofworkersisnot□N.A.

misleadingorfraudulent?Ifno,explainExplain:

Doesthecompanyensureemploymentabove□YesDNo

4.3theminimumlegalemploymentage?Ifno,□N.A.

explainExplain: