hne - hse forms
DESCRIPTION
Hne - Hse FormsTRANSCRIPT
2.0 HSE Forms
2.1 HNE-HSE-F-01 Contractors Safety Information
2.2 HNE-HSE-F-02 Tool Box Talk
2.3 HNE-HSE-F-03 HSE Meeting Report
2.4 HNE-HSE-F-04 Safety Observation Report
2.5 HNE-HSE-F-05 Environment Incident Report
2.6 HNE-HSE-F-06 Corrective Action Request
2.7 HNE-HSE-F-07 Course Attendance Sheet
2.8 HNE-HSE-F-08 Training Calendar
2.9 HNE-HSE-F-09 Fire Extinguisher Inspection Report
2.10 HNE-HSE-F-10 Safety Violation Notice
2.11 HNE-HSE-F-11 Mobile Crane Entry Permit
2.12 HNE-HSE-F-12 Hot Work Permit
2.13 HNE-HSE-F-13 Confined Space Entry Permit
2.14 HNE-HSE-F-14 Electrical Isolation Permit
2.15 HNE-HSE-F-15 Excavation Permit
2.16 HNE-HSE-F-16 PTW Register
2.17 HNE-HSE-F-17 Incident Notification Form
2.18 HNE-HSE-F-18 Incident Report
2.19 HNE-HSE-F-21 Incident Investigation Report
2.20 HNE-HSE-F-20 Suggestion and Near Miss Card
2.21 HNE-HSE-F-21 Safety Violation Register
2.22 HNE-HSE-F-22 First Aid Register
2.23 HNE-HSE-F-23 Site HSE Checklist
2.24 HNE-HSE-F-24 Emergency Contact
2.25 HNE-HSE-F-25 HSE Induction Record
2.26 HNE-HSE-F-26 Document Distribution record
HNE SAFETY DECLARATION
This information applies to HNE and others sub contractors under their control engaged in carrying out work on the project and premises.
It is HNE’s intention to secure a high standard of health safety and environment compliance in all our areas of control.
HNE will comply with national and local health and safety legislation and codes of practices and Client / Consultant HSE rules / HSE Plan whilst on site.
HNE submit risk assessments and method statements for all activities and get the Client / Consultant approval before carrying out the work. HNE will adhere to the identified control measures while executing the work activity.
When changes in health and safety controls may be necessary, such changes will be informed to the Client / Consultant HSE personnel. This will cover for example hazards, restricted access areas, fire precautions, emergency response, first aid facilities, accident reporting, welfare facilities, smoking restrictions, segregation of work activities, any other issues affecting health and safety.
HNE / CONTRACTOR will be responsible and accountable for all accidents involving their employees and equipment. All accidents will be notified to Client / Consultant HSE personnel as per the Client / Consultant HSE Plan and Policy.
The work area should be left tidy and secure, not only on completion of the work but each time the Contractors leaves project premises.
All Contractors must familiarise themselves with the Client / Consultant HSE rules/Plan.
High risk work e.g. hot work, demolition, excavation, working in confined spaces, working at height, electrical work and any other specified work will not be started unless a 'permit to work' has been obtained. For hot work only, work area must be checked one hour after completion of the works.
If in the opinion of Client / Consultant, Contractors are working in such a manner as to put themselves, employees, visitors any other person, or property and equipment at risk, the contractors can be requested to stop work immediately and rectify the controls.
HNE / Contractors must supply their own PPE, access equipment, electrical equipment / tools and hand tools.
HNE will ensure these terms and conditions are communicated to all their employees working at Company premises.
HNE / Contractor must immediately implement appropriate corrective / preventive actions for any safety issues identified.
Where a HNE / sub contractor employee has been violating safety rules even after being issued with a written warning letter (safety violation), he / she along with his supervisor shall be summoned to the HNE Office; issued with a termination order by the Company HSE Manager and both will be asked to leave the Project premises. The Contractor shall replace the employee with an alternative employee with the same or more competency
I have read the above conditions and accept them.
Signed: ......................................................, Position: ......................................................
On behalf of:.............................................., Date: ............................................................
HNE-HSE-F-01 Page 1 of 1 R: 0 D: 01-07-2012
TOOL BOX TALK RECORD
Contractor/Subcontractor Name:
Following points were discussed in today’s toolbox talk:
a)
b)
c)
d)
Following persons attended the session:
Date:
SL No: Card Number* Name Designation Signature
(* If this pertains to the sub contractor employees, indicate the name of the
contractor) Toolbox talk was given by:
Name :
Position :
Signature :
HNE-HSE-F-02 Page 1 of 1 R: 0 D: 01-07-2012
HSE REVIEW MEETING REPORT
HNE-HSE-F-03
Page 1 of 2 R: 0 D: 01-07-2012
HSE Meeting Number:Members Present Distribution of Minutes
Place:Date: Time:
Minutes recorded by: Signature:
Sl. No
DescriptionAction by/ Target
Date
Closedout (Date& Sign)
1. Purpose and objective of the meeting:
2. Previous meeting points:3. Housekeeping (Edge Protection/ Slab penetration, signs etc):
Housekeeping:
Edge Protection:
4. Welfare measures:
Rest Area: Toilets:Drinking Water:
5. Safety Incentive Scheme:
Safety improvement slips: Suggestion Received:
6. Accidents/ Incidents/ FA cases:
7. Scaffolding and ladders:a. Scaffolds:b. Ladders:
8. Electrical safety:
9. PTW issues:1. Hot Work:2. Barricade Removal Permit System:3. Excavation4. Confined Space5. LOTO
10. HSE Inspections:
11. Induction and Tool box talks:
12. Fire Prevention:
HNE-HSE-F-03
Page 2 of 2 R: 0 D: 01-07-2012
HSE REVIEW MEETING REPORT
13. Emergency preparedness:
14. Lifting Tools & tackles / Hoists:
15. Plant & machineries:
16. Safety training and awareness sessions:
17. Risk Assessments:
18. Sub contractors: -
19. Scope for possible improvement in HSE:
20. Environmental Issues:1. Spillage –2. Waste Water –3. Noise –4. Dust -5. Construction Waste –6. Chemical Waste –7. Chemical Storage –.8. MSDS –
21. Authorities Issues:
22. Safety audit, if any:
23. Storage / Resource:
24. PPE:
25. Security:
26. Any other issues:27. Next meeting:
Next Meeting Date:
HSE OBSERVATION REPORT
HNE-HSE-F-04
Page 1 of 1 R: 0 D: 01-07-2012
Contractor :
Date :
SLNO
OBSERVATIONS ACTION TAKEN
Inspected By :
Report To :
This report shall be returned within 24 hours to the Contractor’s Safety Personnel indicating action taken against the observations made.
ENVIRONMENTAL INCIDENT REPORT
Contractor :
Time of Incident :
Date of Incident :
Air EmissionWater Pollution (Wastewater Discharges / Sanitary Waste) Solid or Hazardous WasteHazardous Materials or Chemicals Used / StoredNoise PollutionOdour / DustWater / Fuel / Electricity ConsumptionOther
Details of Incident
Reported By Date
Root Cause
Investigated By DateAction Taken
Taken By Date
Review & Close out
Carried out By Date
HNE-HSE-F-05 Page 1 of 1 R: 0 D: 01-07-2012
CORRECTIVE ACTION REQUEST
HNE-HSE-F-6 Page 1 of 1 R: 0 D: 01-07-2012
Contractor :
Date :
CAR Ref :
Nonconformity Minor Major Observation
Raised By Date
Results of Investigation & Root Causes
Investigated By Date
Corrective Action
Action Taken By Date
Follow-up Comments
Carried out By Date
COURSE ATTENDANCE SHEET
HNE-HSE-F-7 Page 1 of 1 R: 0 D: 01-07-2012
Course Title
Date
Trainer
Sl Name Designation Company Staff No: Signature
Trainer Signature :
HNE-HSE-F-8 Page 1 of 1 R: 0 D: 01-07-2012
TRAINING CALENDER
Year
Course Title Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Updated on:Date Planned
Date Completed
Signature:
FIRE EXTINGUISHER INSPECTION REPORT
HNE-HSE-F-9 Page 1 of 1 R: 0 D: 01-07-2012
Sl no
Type Of FireExtinguisher
Lo
cati
on
Saf
ety
Cli
p
Pr
Gau
ge
Ho
seC
on
dit
ion
3rd P
arty
Insp
ecti
on
Dat
e O
fIn
spec
tio
n
Rem
ark/
Sig
n
Inspected by :
Signature :
Date :
SAFETY VIOLATION NOTICE
HNE-HSE-F-10 Page 1 of 1 R: 0 D: 01-07-2012
Warning Notice No: DateContractor LocationWarning issued to:
Name:Card / Staff No: Designation:
ApproximateLocation:
Date and Time:
You were found working unsafely at site, which could have resulted in serious accident andthus injuring you and / or others. The violation is as follow:
You were found working unsafely / allowing the operatives working under you to carry out work in on unsafe manner thus putting in danger their lives as well as others working nearby.The violation is as follow:
Is the violator given sufficient training related to the type of violation [Yes / No]
Safety training (Induction, specific training) reference to be attached with reference to the type of safety violation.
This is against our company safety policy and the local rules governing the Health and Safety ofemployees. The following action will be taken against you:
Repetition Nos. Action Taken
1st
Warning/
Repetition
The employee will be called during the toolbox talk and will be asked to address others thecircumstances in which he was forced to take the shortcut (follow the unsafe practice) and how it can be avoided; he has to also apologize for the said act and promise the whole group that he will not repeat the same in future
2nd
Warning/
Repetition
Concerned employee along with his supervisor will be asked to report to the Company HSE Manager. Contractor HSE Officer shall coordinate this. After appropriate counselling, bothof them will be issued with a warning letter.
3rd
Warning/
Repetition
The Contractor employee, along with his supervisor shall be summoned to the CompanyOffice; issued with a termination/ de-mobilized notice by the Company HSE Manager and shall not be allowed to work within the Company premises.Any Contractor staff found working within the Company premises without a valid (UAE)work permit; he/she along with his supervisor shall be issued with a termination/ de-mobilized notice immediately by the Company HSE Manager and will be asked to leave Company premises. Contractor will be given 24hours to submit the original work/permit to Company HSE, failing which contractor will be asked to permanently demobilize the identified staff and his immediate supervisor from the site.
Safety violation noticed by: Safety Warning issued by: Warning Accepted by:
Name:Designation:
Signature:
MOBILE CRANE ENTRY PERMIT
HNE-HSE-F-11 Page 1 of 1 R: 0 D: 01-07-2012
Contractor Name: Date: Permit No:Vehicle No: Capacity: Place:
SL Check Points Yes No Remarks
Section 1: Document Verification (Mandatory) – to be checked by site engineer
1 UAE valid Crane Registration with at least one month validity uponentry
2 UAE valid Driving License of the operator
3 Valid Third Party test Certificate for crane (Every 12 Months)
4 Valid Operators Third Party Competency Certificate
5 Test certificate for the Lifting Gear available in the crane
Name & Signature:
Section 2: Physical Condition of Equipment – to be checked by Site engineer / Site Supervisor
1 Display/Availability of Load chart in crane.
2 Automatic safe load indicator/ Top Limit Switch
3 Audible alarm linked to safe load indicator
4 Automatic Reverse Horn
5 Out riggers with base supports in good condition
6 Rear /Side view mirrors (as Applicable)
7 Free from Hydraulic Oil Leakage /Diesel
8 Availability of safety Latch in the slings and lifting hook
9 Warning Lamps /Lights (Night Working)
10 Proper functioning of control levers/brakes/Steering
Name & Signature
Section 3: Operators Assessment - to be checked by Safety
1 Site safety rules and norms
2 Safety awareness & Emergency Preparedness
3 Knowledge of job to be executed.
Name:
Signature:
Equipment is Authorized to enter the site
HOT WORK PERMIT
HNE-HSE-F-12 Page 1 of 1 R: 0 D: 01-07-2012
Contractor Name: Date: Permit No:Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)Location of the hot work (indicate level and grid no and enclose location sketch if required):
Description of the work: Arc welding / C utting / Grinding near flammables / Soldering / Brazing /Metal cutting / Electric Cable termination and jointing
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only for
relevant ones) or mark as X No flammable/combustible materials around/below
the work spot. Suitable Fire Extinguisher and trained personnel
(Operation of Fire extinguisher) at the work place Wet gunny bag/fire resistant sheet to arrest flying spark Welding m/c with proper insulated welding
cable/lugs Standby person for watching falling molten metals. Welding & supply cable without joints/ damages. Gas cutting torch fitted with Flash back arrestor. Separate Ele. supply cable with ELCB from DB Soap water test conducted for detecting leakage. No criss-cross of power & welding cables Gas Cylinder with proper Pressure Gage & Regulator. Proper/overhead routing of Electrical cables Gas Cylinders with Chain/ trolley to arrest falling. Availability of proper scaffolding/platform/ladder Gas Hose of sound condition & proper hose clips. Proper ventilation Suitable Spark lighter available- never use smoking lighter. Separate permit incase of work in confined space Barriers to avoid exposure of UV / IR rays to passers Safety inducted welder / Helper and others involved Do not gas cut containers of flammable liquids. Required PPE for helper PPE - Helmet Welding Screen Suitable Goggles Welding Apron Dust Masks Leather Hand Gloves Safety Shoes Full Body HarnessAny other precautions (Specify):
I request for a Hot Work Permit for the above-mentioned work at the location specified above. I have personally inspected the work place to ensure that the applicable precautions mentioned above have been complied with.
Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):
Name: Signature:
Section III: (Permit Approval - To be filled by authorized Issuer)I have personally verified the work spot and compliance of the relevant precautions given insection II of this permit.
The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).
Name of the concerned engineer (Authorized Issuer): _ _ _ _ _ Signature: _ _ _ _ _
Section IV: (Permit close out cum Revalidation details)(To be returned to the authorized approving authority immediately after the completion of work for
closing / revalidation at the end of the work everyday)
Revalidation datesSign of Receiver for proper closing the work with time.Sign of Receiver for proper starting the work on next day with time.Sign of Issuer for proper starting the work on next day with time.
Note:1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety2. The permit must be registered and a unique number to be given for each permit for follow up.3. This permit is not valid for cutting containers of flammables.4. This permit is valid for the location mentioned in section I and for one day only. Can be
revalidated (if location is not changed) on a daily basis for a maximum period of one week.
5. Permit can be cancelled at any time if any violation observed.
CONFINED SPACE ENTRY PERMIT
HNE-HSE-F-13 Page 1 of 1 R: 0 D: 01-07-2012
Contractor Name: Date: Permit No:Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)Location of the work (indicate level and grid no and enclose location sketch if required):
Description of the work /Reason for Entry:
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only for relevant
ones) or mark as X Suitable & Sufficient access provided to the
confined space? All the employees trained in working in confined space?
Required warnings signs (Danger – Restricted Entry, Permit Required), Emergency Contacts no displayed
Gas test been done to check the absence of flammable gases
If any other gases are anticipated, has it been checked? Have low voltage & flameproof lighting been arranged? Confined space checked for oxygen deficiency All concerned persons been informed Enough ventilation ensured. Entrants provided with emergency lights A stand-by (Buddy) is deputed outside the manhole /
confined space In-Out Register ready to maintain / Available with
buddy All entrants provided with safety harness with long
lifeline Necessary safety appliances been provided
Any other precautions (Specify): LEL
Oxygen
I request for a Confined Space Entry Permit for the above-mentioned work at the location specified above. I have personally inspected the work place to ensure that the applicable precautions mentioned above have been complied with.
Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):Name: Signature:
Section III: (Permit Approval - To be filled by authorized Issuer)I have personally verified the work spot and compliance of the relevant precautions given insection II of this permit.The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).Name of the concerned engineer (Authorized Issuer): _ _ _ _ _Signature_ _ _ _ _ _ _
Section IV: (Permit close out - To be filled by authorized Receiver)(To be returned to the authorized approving authority immediately after the completion of work)The said job is completed and all the entrants have come out from confined space. Name(Authorized Receiver): Signature:
Date and Time:
Note:1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety2. The permit must be registered and a unique number to be given for each permit for follow up.3. Percentage of O2 should not be less than 20%4. This permit is valid only for the location mentioned in section I and for one day only.5. Permit can be cancelled at any time if any violation observed.
ELECTRICAL ISOLATION PERMIT
HNE-HSE-F-14 Page 1 of 1 R: 0 D: 01-07-2012
Contractor Name: Date: Permit No:Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)Location of the work (indicate level and grid no and enclose location sketch if required):Test Description: Test Equipment:
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only for
relevant ones) or mark as X
Competent working crew has been deputed Sufficient training conducted for concerned staff and documented
Power supply switched off Circuit breaker Deactivated Isolator switch locked* Required warning notices” DANGER”, “RESTRICTED
ENTRY”, “HIGH VOLTAGE TESTING IN PROGRESS”,“NO SMOKING” etc are provided
Earthing available
All testing equipments are calibrated and sticker available
All floor & roof openings are covered and barricaded
Stand by (Buddy) Provided Emergency Contacts are displayed. Fiber ladder is available for testing work. Testing area identified and barricaded Area is free from flammable and
combustible materials Suitable Fire Extinguishers are provided
ELCB available with supply source DB Illumination is sufficient Necessary safety appliances provided Unauthorized entry is restricted by suitable meansAny other precautions (Specify):
I request for a Pre Commissioning Testing Permit for the above-mentioned work at the location specified above. I have personally inspected the work place to ensure that the applicable precautions mentioned above have been complied with.
Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):
Name: Signature:
Section III: (Permit Approval - To be filled by authorized Issuer)I have personally verified the work spot and compliance of the relevant precautions given insection II of this permit.
The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).
Name of the concerned engineer (Authorized Issuer): _ _ _ _ _ _Signature _ _ _ _ _ _
Section IV: (Permit close out - To be filled by authorized Receiver)(To be returned to the authorized approving authority immediately after the completion of work) The said job is completed and the equipment is safe for re-energizing. Name(Authorized Receiver): Signature:
Date and Time:
Note:1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety2. The permit must be registered and a unique number to be given for each permit for
follow up.3. All dead cables shall be terminated with insulation properly during / after test.4. This permit is valid only for the location mentioned in section I and for one day only.5. Permit can be cancelled at any time if any violation observed.6. *- The key shall be available only with the technician performing the job
EXCAVATION PERMIT
HNE-HSE-F-15 Page 1 of 1 R: 0 D: 01-07-2012
Verification of the condition of shoring at regular intervals Usage of PPE such as Verification of the condition of handrails, access, flashers etc Storage of surplus earth at least m away from the edges of excavation Block stops at the edges of excavation to limit the access of vehicles Emergency escape (evacuation procedures) Construction equipment exhaust away from excavation
Contractor Name: Date: Permit No:Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)Location of the work (indicate level and grid no and enclose location sketch if required):Description of the work:
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only for
relevant ones) or mark as X Required permit for buried services has been
obtained from the concerned authority. Workers are given training – Risk Identification
and Precaution Are all the buried services located (with the
help of drawings and by trial pit, detectors etc) Required caution boards / warning notices are
provided Is Shoring / sloping required? If so, has the
material been arranged? Barricades / Handrails installed around the
proposed excavation site The access details to the pit finalized and
materials arranged accordingly Are any traffic diversion signs / flashers required If
yes are these items provided? Following additional precautions shall be taken after taking up the excavation work: (Tick relevant boxes
alone)
I request for an Excavation Permit for the above-mentioned work at the location specified above. I have personally inspected the work place to ensure that the applicable precautions mentioned above have been complied with.
Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):
Name: Signature:
Section III: (Permit Approval - To be filled by authorized Issuer)I have personally verified the work spot and compliance of the relevant precautions given insection II of this permit.The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).Name of the concerned engineer (Authorized Issuer): _ _ _ _ _ _Signature_ _ _ _ _ _
Section IV: (Permit close out - To be filled by authorized Receiver)(To be returned to the authorized approving authority immediately after the completion of work)Name(Authorized Receiver): Signature:
Date and Time:Note:1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety2. The permit must be registered and a unique number to be given for each permit for
follow up.3. Ensure the no residual risk after completion of work.4. This permit is valid only for the location mentioned in section I and for one day only.5. Permit can be cancelled at any time if any violation observed.
PERMIT TO WORK REGISTER
DATEPERMIT NUMBER
PERMITTYPE
LOCATION ISSUER NAME
RECEIVER NAME
SUB - CONTRACTOR
(if any)
REVALIDATION / CLOSING STATUS
WRITE REVALIDATION DATE
HNE-HSE-F-16 Page 1 of 1 R: 0 D: 01-07-2012
INCIDENT NOTIFICATION FORM
Contractor Name: Date :Employee Name (s): Card No / Staff No:
Age: Designation / Category:Contact Number:
Name of the Concerned Engineer/Foreman:Contact number concerned engineer/foreman:
Witness of Accident (Name, Designation, Contacts):
Person (s) Involved:Card No / Staff No Name Designation Employer
Circumstances and brief description of the Incident / ill health:
Immediate Action taken after the Incident / ill health:
Injury / Illness Details:Nature / Extent of Injury or Illness /
Disease:Location of Accident:
Date & Time:Present Condition:
Referral Details (If applicable):Hospital / Clinic:
Ward No / Bed No:
Name & SignatureFirst Aid Provider Safety Engineer / PM / CM
Note: This form is to be filled immediately in case of injury / illness immediately and submitted to Company HSE Personnel.
HNE-HSE-F-17 Page 1 of 1 R: 0 D: 01-07-2012
HSE INCIDENT REPORT
HNE-HSE-F-18 Page 1 of 1 R: 0 D: 01-07-2012
EmployeeName
Date of Incident
Job Title Time of IncidentType of InjuryLost Time Injury Yes No Nature of Injury Major
MinorNo. of Days/ hours Lost
Property Damage Yes No Extent of Damage
Incident Description
Primary Cause
Contributory FactorsProtective Equipment not used Yes No Inattention Yes NoProtective Equipment notavailable
Yes No Fatigue Yes No
Identified controls and giveninstructions not followed
Yes No Defective Equipment Yes No
Lack of Communication Yes No Poor Judgment Yes NoLack of Training Yes No Poor Housekeeping Yes NoContributory Negligence byOthers
Yes No Shortcuts Yes No
Reported By: DateAction Taken
Reviewed By: DateThis report to be submitted to the Company HSE personnel by the contractor within 24 hours for all HSE
incidents (accidents & near miss)
INCIDENT INVESTIGATION REPORT
HNE-HSE-F-19 Page 1 of 4 R: 0 D: 01-07-2012
Section 1 - Incident Details:Incident Investigation Report No
Date of IncidentTime of Incident
Exact Location of IncidentNature of Incident Over 2 Days
Hospital referral case (< 2 days)Fatality
Dangerous Occurrence / NearmissFIRE
Property DamageEnvironment Disturbance
Other (specify)Type of injury (If any) : Bruise Sprain
Fracture CutAmputation Crush
Burn Electric ShockPuncture wound Heat Related Illness
Eye Injury Other (State)
Details of Damage (If any):
Details of the plant / Equipmentinvolved in the Incident:
Incident Reported By (Name andPosition):
Section 2 – Injured Person (s) Details:Name (s):
Name of Sub Contractor (If any):Card No / Staff No:
Designation / Category:Age:
Experience:Training Attended / Experience:Include the induction, related TBT, job specific training given – attach records
INCIDENT INVESTIGATION REPORT
Section 3A – Person Involved (Details):Name of Sub Contractor (If any)
Name of Concerned Engineers:Name of the person involved:
Designation / Category:
Card No / Staff No:Age:
Section 3B – Witness Details:Name Position Contact No Company
Section 4 - Circumstances and description of the Incident:
Section 5 – Facts observed during investigation:
Section 6 – Casual Factors:
Immediate / Underlying Cause Root Cause
Section 7 – Control measure present while Incident:
HNE-HSE-F-19 Page 2 of 4 R: 0 D: 01-07-2012
INCIDENT INVESTIGATION REPORT
Section 8 – Recommendation / Action to be taken to avoid recurrence:
Sl. RecommendationsTargetDate
Close outdate
Incident investigation conducted by, Submitted to,
Name Designation Signature
Project Manager / Construction Manager
Add pictures of IncidentsPicture 1 Picture 2
HNE-HSE-F-19 Page 3 of 4 R: 0 D: 01-07-2012
INCIDENT INVESTIGATION REPORT
Picture 3 Picture 4
Distribution:
HNE-HSE-F-19 Page 4 of 4 R: 0 D: 01-07-2012
SU GG ES TI O N / N E A R M I SS/ UNSAFE ACT/ UNSAFE CONDITION CARD
Contractor DateEmployee Name Location.
Section 1: Problem Description (Please write what you observed, you may write in any language)
Section 2: What is your suggestion / recommendation to eliminate the problem?
Section 3: Expected benefits from your suggestions:
Section 4: Reviewer - Safety Supervisor/Safety Manager
Section 4: Comments from Client Project Director
Staff/Card No Name Designation Signature
HNE-HSE-F-20 Page 1 of 1 R: 0 D: 01-07-2012
SAFETY VIOLATION REGISTER
Detail of the Violator: Details of the Violation:Name of the supervisor
SI Slip Issued
ByRemarksSl
NoCompany Name Employee
NameCard
number*Date Exact
locationDescription of the Violation
Note: * If the violator belongs to a sub contractor, indicate the name of the company.
HNE-HSE-F-231 Page 1 of 1 R: 0 D: 01-07-2012
FIRST AID REGISTER
Detail of the injured: Details of the accident:Name of the supervisor
RemarksSL Name
Card number* Category Age Date Time
Exact location
Part of body
injured
Brief Description of the Accident**
Date and time of returningback to work
* If the injured belongs to a sub contractor, indicate the name of the company.** Mention what the injured was doing, the equipment, material he was handling at the time of accident etc.
HNE-HSE-F-242 Page 1 of 1 R: 0 D: 01-07-2012
HSE WEEKLY INSPECTION CHECKLIST
PROJECT NAME:Sl No Description Observation Remarks Action By
EXCAVATION
SCAFFOLDS
CONCRETING
WORK AT HEIGHT
MATERIAL HANDLING
GRINDING
WELDING & GAS CUTTING
PLANT & MACHINERY
HNE-HSE-F-253 Page 1 of 2 R: 0 D: 01-07-2012
ELECTRICAL SAFETY
FIRE PROTECTION
HOUSEKEEPING
PERSONAL PROTECTIVE EQUIPMENT
HEALTH & HYGIENE
ENVIRONMENT
SIGNATURE WITH DATE :
HNE-HSE-F-23 Page 2 of 2 R: 0 D: 01-07-2012
EMERGENCY PREPAREDNESS – CONTACT LIST
NAME DESIGNATION TELEPHONE NUMBER
Updated On:
Updated By:
HNE-HSE-F-274 Page 1 of 1 R: 0 D: 01-07-2012
HSE INDUCTION RECORD
Company: Date: Time:
Important Note: When you sign below you are agreeing that you have understood induction and that you know the site regulations on the topics listed below:
- Project Details- Saverglass HSE Policy- First Aid arrangements- Medical Facilities- Accident Prevention
- Accident Reporting- Emergency Numbers- Housekeeping- Fire Prevention- Hot Work Permits
- Excavation Safety- Traffic Management- Smoking Policy- Evacuation Procedure- PPE
Sl Name Company Designation Signature
1
2
3
4
5
6
7
8
9
10
Induction By: Name Sig. Date
Witnessed By: Name Sig. Date
HNE-HSE-F-285 Page 1 of 1 R: 0 D: 01-07-2012
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HNE-HSE-F-296 Page 1 of 1 R: 0 D: 01-07-2012