Fields marked with an asterisk (*) are required.
Company and legal representative details
Company name*
First name and surname of the legal representative*
As the legal representative of the aforementioned company, I hereby certify, by means of this document, compliance with the legal requirements specified in Royal Decree 171/2004 of 30 January, which implements Article 24 of Law 31/1995, of 8 November, on the prevention of occupational risks, in matters of Coordination of Business Activities, and Royal Decree 1627/1997, of 24 October, establishing the minimum safety and health provisions on construction sites .
In this regard, the company certifies that:
The company has the following preventive measure in place
Prevention service (PS)
Own prevention service* Yes No
Joint prevention service* Yes No
Third-party prevention service* Yes No
Others
Specialities of the SP
Workplace safety* Yes No
Industrial hygiene* Yes No
Ergonomics and Psychosociology* Yes No
Health surveillance* Yes No
Details of the person designated by the company as the liaison with the UB
First name and surname*
Position*
E-mail*
Accident at work and occupational disease cover is arranged with
Legal name/MATEPSS code
Address
Telephone number/E-mail
Administrative and tax information
Has a valid and up-to-date public liability insurance policy* Yes No
They are up to date with their tax obligations* Yes No
Be up to date with Social Security payments and self-employed contributions* Yes No
Their staff are registered and up to date with their National Insurance contributions (TC1/TC2)* Yes No
Details regarding the Faculty/Centre/Work Area and activity to be carried out
Faculty/Centre*
Order number*
Reference number*
Activity to be carried out*
Auxiliary means and individual and collective protective measures that will be necessary to carry out the work to be performed
Data relating to subcontracting
Is there subcontracting in this action?* Yes No
Name of the subcontracted company/ies
Activities to be carried out by these companies
Name of the worker
The contractor shall ensure that subcontracted companies comply with the necessary health and safety obligations for the proper execution of the works, in accordance with current legislation, and have the appropriate training, protective equipment and accreditations to work at the site where the tasks are to be carried out.
Data relating to the type of work
Tipus d'obra A. Minor works without a project: low complexity and short duration* Yes No
B. Minor works without a project that do not involve special risks(2) * Yes No
C. Minor works without a project involving special risks(2) * Yes No
D. Minor works with a project that does not involve special risks(2) * Yes No
E. Minor works involving a project that entails special risks(2) * Yes No
Contracting by tender* Yes No
(2) According to Annex II of Royal Decree 1627/1997
Data relating to Site Health and Safety
It is an action without a project.* Yes No
It is an action with a project, and this includes a Basic Safety and Health study or a Safety and Health study* Yes No
A safety coordinator has been appointed in accordance with Royal Decree 1627/1997* Yes No
A preliminary site visit was carried out at the start of the works to establish the preventive measures to be taken into account* Yes No
The company undertakes to inform UB immediately of any health and safety requirements that could not have been determined in advance during the activity planning visits, and will prevent and/or completely halt the activity until any necessary health and safety measures have been implemented* Yes No
Documentation to be provided by the company
Preventive Management Document for the Work* Yes No NA
Safety and Health Plan (SHP)* Yes No NA
Communication of the opening of the workplace* Yes No NA
Issue of PPE certificate* Yes No NA
CAE minutes with subcontracted companies* Yes No NA
Minutes of the CAE with third-party companies also involved in the project* Yes No NA
Adhesion of subcontracted companies to DGPO or PSS* Yes No NA
Appointment of a Preventive Recourse* Yes No NA
Specific documentation in the case of special risks* Yes No NA
This documentation is the minimum required. The contractor undertakes to provide any documentation requested by the appointed safety coordinator in accordance with the specific characteristics of the works.
Other documentation provided
Data relating to risk prevention
In the case of subcontracting, it has established the appropriate coordination measures with its subcontractors or self-employed workers providing services at the UB's facilities, as provided for in Royal Decree 171/2004* Yes No
Do you have a prevention plan?* Yes No
It has carried out the risk assessment and the planning of preventive activities for the tasks its staff will perform, including the services to be provided at the University of Barcelona, in accordance with current regulations* Yes No
Its staff have the necessary skills, professional training and experience to carry out the tasks to be performed* Yes No
Their staff have been informed and trained on the risks of the activity to be carried out, and on the preventive and emergency measures to be applied* Yes No
For specific or particularly hazardous activities (work at height, confined spaces, electrical risk, etc.), workers have the specific, adequate and sufficient training required to carry them out safely* Yes No NA
In cases where so stipulated by the current regulations (Law 54/2003 and Royal Decree 604/2006), the necessary preventive resources shall be designated* Yes No NA
Their staff hold the medical certificates attesting to their specific occupational fitness for the activities to be carried out, or, failing that, the waiver document for the health examination* Yes No NA
Has instructions and/or work procedures for the tasks to be carried out* Yes No NA
All work equipment required for the activities to be carried out is suitable in accordance with the applicable current regulations (RD1215/1997, EC Directive, ATEX Directive, among other applicable regulations) and is in good working order and condition* Yes No NA
Their workers have the necessary personal protective equipment for carrying out the contracted work in accordance with the activity's risk assessment* Yes No NA
When handling chemical products, your staff have the Safety Data Sheets (SDS) and have been informed of their contents and properly trained to handle them safely* Yes No NA
They undertake to inform the University of Barcelona immediately of any accidents or emergencies that occur during the course of the activities* Yes No
In the event of any change, replacement, resignation or new appointment of staff providing services to the University of Barcelona, this must be communicated immediately* Yes No
In case of application
The vehicles required for the provision of contracted services have a valid, paid-up accident insurance policy, a valid road tax disc, a valid vehicle registration document and a valid periodic vehicle inspection certificate, as stipulated by the General Vehicle Regulation* Yes No NA
In cases where stipulated by the Industrial Regulations, the company is officially authorised to carry out installation, maintenance, inspection and review work on installations and/or equipment subject to these specific regulations* Yes No NA
In the event that Law 32/2006 regulating subcontracting, as developed by Royal Decree 1109/2007, applies, the company is registered on the Register of Accredited Companies for the Construction Sector (REA)* Yes No NA
In the event of applying RD396/2006, concerning the carrying out of work involving a risk of exposure to asbestos, the company is registered on the RERA and has the work plan for the tasks to be carried out, approved by the competent authority* Yes No NA
Working staff
To communicate the list of employees, you have two options: attach a file containing the list of employees or specify it in the following box.
Archive with the list of staff (Maximum size: 2MB - Accepted extensions: .pdf, .txt, .docx, .xlsx)
Workers (One person per line. For each worker, whether employed or subcontracted, please specify their first name, surname and the location where they will be working)
Prior to the start of work, the company shall be in a position to documentally substantiate all the regulatory requirements in the field of OHS as set out in the current company declaration to the UNIVERSITY OF BARCELONA and any that may be required by the safety coordinator appointed for the project. The company undertakes to update it in the event of any changes.
I certify that the institution I represent is in a position to provide documentary evidence to the UB for all the information provided in this declaration, and that it undertakes to update it should any changes occur*
Signature of the person designated as the company's contact*(Draw your signature in the box)
Organisation receiving the information: University of Barcelona
Right to information regarding the processing of personal data detailed information on the treatments mentioned .
I declare that I have read the right to information*
I declare that I undertake to provide the information regarding the processing of personal data by the UB, as set out on this page, to the employees of the entity I represent*
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