Pre-Qualification Questionnaire ACR is required under the terms of the Health and Safety at Work Act 1974 & the Construction Design Management Regulations 2015 to complete an assessment of all Contractors used behalf of their Clients, to ensure they are complying with the current Health and Safety regulations. If your company has five or more employees, you must be aware of the duties placed upon employers by the Health & Safety at Work Act 1974, the management of Health & Safety at Work Regulations 1999, and the Construction (Design & Management) Regulations 2015. Step 1 of 12 8% Contractor DetailsCompany NameDate of formation or registration Date Format: DD slash MM slash YYYY Company Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Company Registration No.VAT Registration No.Service desk details for reactive and planned maintenance.PhoneEmail Number of directly employed staffOut of hours service provided?Please selectYesNoEmergengy Telephone NumberPlease provide emergency telephone number. Description of WorksPlease state the type of work you will be carrying out.Please state the maximum travel distance in miles you will consider for works.Provide examples of the type, scope and size of project the company carries out. Drop files here or If your work involves the installation, service or routine maintenance of fixed refrigeration / air conditioning equipment, your F-gas Company Certificate must be attached. As of 4th July 2011 this must be a Full Certificate.Upload: F-gas Company Certificate Use of Sub-ContractorsDoes the company employ Sub-Contractors?Please select...YesNoUpload: Please supply completed Pre-Qualification Questionnaire and current insurances for each subcontractor used to assess competence.Documentation must be submitted for each sub-contactor used. Failure to do this will result in the removal from the approved contractor database. Drop files here or Insurance DetailsPlease provide details of your current insurance cover.Public LiabilityPlease select...YesNoPublic Liability CoverRenewal Date DD MM YYYY Upload: Public Liability DocumentPlease attach copies of your current certificates which specify these limits of indemnity Drop files here or Employers LiabilityPlease select...YesNoEmployers Liability CoverRenewal Date DD MM YYYY Upload: Employers Liability DocumentPlease attach copies of your current certificates which specify these limits of indemnity Drop files here or Professional IndemnityPlease select...YesNoProfessional Indemnity CoverRenewal Date DD MM YYYY Upload: Professional Indemnity DocumentPlease attach copies of your current certificates which specify these limits of indemnity Drop files here or Contractors All RisksPlease select...YesNoContractors All Risks CoverRenewal Date DD MM YYYY Upload: Contractors All Risks DocumentsPlease attach copies of your current certificates which specify these limits of indemnity Drop files here or Health and Safety PolicyThis section is not compulsory if you currently employ less than 5 people.Upload: Health and Safety StatementPlease attach your company's Health and Safety Policy statement Drop files here or Upload: Environmental Policy StatementPlease attach your company's Environmental Policy statement Drop files here or How are the requirements of Safety Policy drawn to the attention of your employees? Health & Safety ResponsibilitiesWho is the most senior person employed with overall responsibility for health and safety within your organisation?Name First Last Position*Who is the competent person who provides health and safety advice to your organisation?Name First Last Qualification(s)Is the person named above:Please select:An employeeConsultantUpload: Organisational ChartsPlease attach organisational chart showing Heath and Safety responsibilities within your organisation. Drop files here or Training and QualificationsHave all operatives received appropriate training and hold relevant qualifications in respect of the work they will undertake on our behalf?*Please select...YesNoUpload: Please attach copies of certificates Drop files here or Have all employees received sufficient safety training?*Please select...YesNoUpload: Please attach copies of certificates Drop files here or Are training records kept and available for inspection?*Please select...YesNoNote: If sub-contractors are used, it is your responsibility to maintain all training records and relevant qualifications. Accident and Enforcement HistoryPlease provide details of your accident record for the following periods:FatalitiesCurrent YearLast Year*Previous YearMajor Reportable (RIDDOR)Current YearLast YearPrevious YearOver 7 Day Incidents (RIDDOR)Current YearLast YearPrevious YearOver 3 Day IncidentsCurrent YearLast YearPrevious YearLost time - Under 3 daysCurrent YearLast YearPrevious YearNo lost timeCurrent Year*Last Year*Previous Year*Please provide details of any Prohibition Notices, Improvement Notices or Prosecutions received from the HSE, Local Authorities or the Environment Agency in the last five years.* Risk Assessment & Method StatementsPlease give details of your Risk Assessment procedure and attach examples. Please include COSHH and Manual Handling Assessments.*Upload: Please attach associated documents Drop files here or Please give details of your Method Statement procedure and attach an example.*Upload: Please attach associated documents Drop files here or Before commencing any works all site permits / certificates for specialised work or use of specific equipment and site specific risk assessments and method statements must be submitted and approved. Additional InformationDo you operate a Quality Management / Assurance System?*Please select...YesNoUpload: Quality Management System DocumentPlease attach a copy of the approval certificate. Drop files here or Do you operate an Environmental Management System?*Please select...YesNoUpload: Environmental Management certificatePlease attach a copy of the approval certificate. Drop files here or Do you operate a Health and Safety Management System?*Please select...YesNoUpload: Health & Safety certificatePlease attach a copy of the approval certificate. Drop files here or Do you hold membership to any specialist safety related organisation? (eg. Chas, Safecontractor etc.)*Please select...YesNoUpload: Specialist safety certificatesPlease attach a copy of the approval certificates. Drop files here or Do you hold membership to any trade institution? (HVAC, NCEIC, Gas Safe etc)*Please select...YesNoUpload: Trade institution certificates*Please attach a copy of the certificates. Drop files here or Do you have a Waste Carriers Registration Certificate?*Please select...YesNoUpload: Waste Carriers CertificatePlease attach a copy of the certificate.Please provide any additional information that will assist us in determining the competency of your company to undertake work on our behalf.* Procedural RequirementsThere are set procedures in place between ourselves as Facilities Management provider and our Clients and you must follow these procedures in order to continue as an Approved Contractor. You will be contacted by the ACR Helpdesk to carry out Reactive/Planned works (within office hours), and a Work Request will be emailed to you. You will only be contacted by the Client if a call out is required out of hours (if this service is provided). If you do respond to an out of hours call, you must contact ACR with the details of the call out as soon as possible after the event (within office hours), so that it can be logged retrospectively. On completion of works, the ACR Work Request must be signed by site and you must return it to ACR advising of the cost. Invoices will not be authorised without a signed Work Request (with the exception of emergency calls). ACR will obtain a Purchase Order Number from the Client (where costs are known) prior to the works being carried out or on completion of reactive works and this will be forwarded to you for invoicing purposes. Invoices should be made payable to (the Client) who is responsible for payment and sent to ACR (the Managing Agent) for initial processing. Invoices must NOT be sent directly to the Client, as the invoice will not be processed without ACR authorisation. All associated paperwork (Quotations. Contract Renewals, Service Sheets, Completed Work Requests, Risk Assessments, Method Statement etc.) should be addressed to the Client but sent to ACR. Paperwork must not be sent directly to the Client. You must provide the latest copy of your Public Liability Insurance to ACR as part of the PQQ process and at the time of renewal. DeclarationIt is a requirement that you, your employees and any others under your control, comply with the Health & Safety at Work Act 1974, the Management of Health & Safety at Work Regulations 1999 and the Construction (Design and Management) Regulations 2015. I/We confirm the details given above are correct and that it is our duty to inform you immediately of any changes to the information.Signed*Date* Date Format: DD slash MM slash YYYY NameThis field is for validation purposes and should be left unchanged.
