Corporate Responsibility Self Assessment v 3.0
© Siemens 2012, All Rights reserved.
Munich, July 2012
Dear Partners,
Sustainability is a strategic and managerial approach integrating our economic,
environmental and social performance in order to create and protect tangible and
intangible value in an ethical way.
For us, Sustainability in the Supply Chain means using excellent and innovative
suppliers to generate long-term added value - and acting with clear economical,
ecological and social responsibility. We can achieve this only by working even more
closely with our suppliers and integrating our sustainability principles into all relevant
business processes.
Siemens expects all suppliers to demonstrate their commitment towards the
standards and principles stated in the Code of Conduct for Siemens Suppliers
(www.siemens.com/scm/code-of-conduct).
We are convinced that shared rules and agreements in our business partnership can
lead to ecological, social and economic improvements for society.
Therefore' in accordance with our "Corporate Responsibility in the supply chain", we
would appreciate your co-operation in undertaking the following self-assessment
(Corporate Responsibility Self-Assessment).
Meeting the set minimum Corporate Responsibility requirements is very important in
the selection of new suppliers. Every supplier must conform to the minimum
requirements of the Code of Conduct for Siemens Suppliers. If the self-assessment
shows a strong indication of a potential risk regarding Corporate Responsibility
issues and this result is confirmed during an inspection, this can lead to an intensive
development program or the termination of the partnership. This assessment is in
both our interests.
If you have any questions regarding the completion of this questionnaire, please do
not hesitate to contact your responsible purchase manager or send an email to:
[email protected]
Yours faithfully
Siemens
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General Information
Company information
0.01 Name and legal form of your company
0.04 City
0.02 Street
0.05 Country
0.03 ZIP code
0.06 D-U-N-S® Number (if available)
Who is the contact person within your company for the topic of sustainability / corporate
responsibility / corporate social responsibility?
0.07 Name of responsible contact
0.09 E-mail address
0.08 Telephone number
0.10 Organization / Function
0.11 Does your company have a program in place to manage adherence with your own and/or
customers’ sustainability requirements?
Yes
No
0.12 Has your company undergone a sustainability audit during recent years?
(If “No”, please continue with question 0.17)
Yes
No
0.13 Who performed the audit/assessment?
An independent audit firm (e.g.
SGS, Intertek, BV, TÜV)
Other customer auditors
Other
0.14 If “Other”, please specify :
0.15 Audit / Assessment completion date :
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0.16 What was the scope of the audit?
Sustainability programs: EICC,
BSCI, WCA
Auditor program by
another customer on the
topic of sustainability
Other
If “Other”, please specify :
0.17 Please select the option below that best describes your company.
Exclusively operating in administration,
management, services, marketing, sales
consulting
Manufacturing and processing industry (e.g.
chemical engineering, heavy engineering,
mechanical engineering, logistics (with and
without hazardous substances), electrical
engineering, etc.)
0.18 How many people does your company employ?
0.19 In which country is your headquarters located?
0.20 In which country is/ are your main production / service site(s)? (List all that apply)
We, as supplier, undertake to ensure that all companies affiliated to us and maintaining a
supply relationship with Siemens AG or one of its affiliated companies fulfill the obligations
assumed by us in this module, too.
Yes
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No
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1. Compliance with legislation and prohibition of corruption and bribery
1.1 Is a member of your company's executive management (e.g. director) nominated with
responsibility for combating corruption, bribery, and antitrust violations?
Yes
No
1.2 Has your company been involved in legal proceedings regarding corruption, bribery, or antitrust
during the past 5 years?
Yes
No
1.3 Do you have an implemented company-wide Compliance program or procedures? (minimum
requirements: Compliance communication and training for relevant employees, process specifying
how compliance cases of bribery or corruption and antitrust should be internally handled)
Yes
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No
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2. Respect for the basic human rights of employees
2.1 Do you have internal regulations aligned with local legislation that govern the maximum number
of working hours for your employees?
Yes
No
Please state the maximum number of working hours per week:
2.2 Do you have rules that govern the maximum number of consecutive working days for your
employees?
Yes
No
Please state the maximum number of consecutive working days:
If “No”, please specify :
2.3 Do you contravene ILO (International Labor Organization) conventions by imposing monetary or
other relevant sanctions on employees? www.ilo.org
Yes
No
2.4 Do you keep records of your employees' working hours (including overtime) and wage payments
in order to ensure compliance with ILO (International Labor Organization) standards and local
legislation? (The stricter regulation applies)
Yes
No or only partially
If "No or only partially", please specify:
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2.5 How often are salaries paid to employees at your company / facility?
Monthly / more than once per month
Every two months or less
2.6 Does your company provide an opportunity for your employees to give feedback & complaints to
management?
Yes
No
2.7 Is your company's pay equal to or above the legally regulated minimum wage? (If there is no
legally regulated minimum wage, do you provide fair remuneration?)
Yes
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No
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3. Prohibition of child labor
3.1 Does your company have a guideline regulating the minimum age for employment that is aligned
with the minimum requirements of local legislation and the ILO (International Labor Organization)
convention? (The stricter regulation applies)
Yes
No
Please specify minimum age:
3.2 Do you check and verify the age stated by your employees during the hiring process, including
when hiring through recruitment agents, headhunters, etc?
Yes
No or only partially
3.3 Do you keep copies of legal proof of age documentation on file for all employees? (Only required
if you answered "Yes" to 3.2)
Yes
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No
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4. Health and safety of employees
Further information on the Code of Conduct for Siemens Suppliers, Occupational Health and Safety
Section, as of 2008
https://w9.siemens.com/cms/supply-chain-management/en/supplier-at-siemens/basicinformation/environment/management/Pages/management.aspx
4.1 Is your company / facility certified to OHSAS 18001? (If "Yes", please continue to section 5)
Yes
No
4.2 Does your company have a health and safety policy that is adequate for your business, which is
communicated in the local language?
Yes
No
4.3 Have you conducted risk assessments to identify risks relating to health and safety in your
business?
Yes
No
4.4 Does your company conduct occupational health and safety training for all relevant employees,
and also keep training records? (e.g. in the safe operation of machines)
Yes
No
There are no processes within our operations that
necessitate training on occupational health and
safety
4.5 Does your company enforce the use of personal protective equipment? (e.g. safety goggles,
safety shoes, ear protection, protective gloves, etc.)
Yes
No
There are no processes within our operations that
necessitate the wearing of personal protective
equipment
4.6 Does your company have a process for providing first aid to injured employees?
Yes
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No
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5. Environmental protection
5.1 Does your company / facility have a certified environmental management system? (If you do not
select "No", please continue to section 6)
ISO 14001
EMAS
No
5.2 Do you have an environmental management system that complies with Siemens minimum
requirements?
https://w9.siemens.com/cms/supply-chain-management/en/supplier-at-siemens/basicinformation/environment/management/Pages/management.aspx
Yes
No
5.3 Is there a management position within your company with nominated responsibility for
implementing local environmental legislation?
Yes
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No
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6. Supply chain responsibility
6.1 Do you use reasonable efforts to promote compliance with the Code of Conduct for Siemens
Suppliers or your own equivalent code among your suppliers? (e.g. in commercial contracts, terms
and conditions of purchase, etc.)
Yes
No
6.2 Is your sourcing decision influenced by compliance with the Code of Conduct for Siemens
suppliers or your own equivalent code?
Yes
No
6.3 Do you take corrective action if you identify a breach of the Code of Conduct for Siemens
Suppliers or your own equivalent code by a supplier?
Yes
No
Date:
Signature:
Place:
_____________________
Company seal:
This document must be signed by an authorized representative of the company and returned to
Siemens.
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