FIRE EXTINGUISHER INSPECTION Form # HSEQ - FEI Rev 4.docx
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This document is a fire extinguisher inspection form to be completed twice weekly. It includes details of fire extinguishers such as their number, type, location, seal, lock, pin, pressure gauge, and discharge hose and nozzle. Inspectors check each fire extinguisher for cracks, breaks, seals and other defects, and note any required repairs or replacements in the remarks section. The inspection is reviewed and noted by safety and project management.
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Radiography Permit
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HSE WARNING LETTER-DISCIPLINARY NOTICE Form # HSEQ - HSEWL Rev 6.doc
1st Warning 0 Ref. No. ______________
2nd Warning 0
3rd Warning 0
4th Warning 0 Date: ________________
Employee’s Name : ______________________________________ M.B No. : __________
Occupation : _____________________________________________________________________
Location / Project Site: _____________________________________________________________________
You have committed the following HSE violation/s:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….….
The employee is hereby warned that if the violation is repeated further disciplinary action can be
taken as per the company Code of Conduct.
ORIGINATOR APPROVED BY (MANAGER IN CHARGE / ARABTEC HSEQ & ORG. RISK Manager)
Name: _______________________________ Name: _____________________________
Designation: _______________________________ Designation: _____________________________
Signature:
_______________________________ Signature:
_____________________________
Employee Acknowledgement:
I the undersigned have received this Safety warning letter / disciplinary notice and I admit that I have understood the contents.
0 Received on: ………………………….. (Date) Signature: ………………………………..…..
WORK AT HEIGHT PERMIT Form # HSEQ - WHP Rev.docx
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Detail of Surroundings:
Permit Validity:
Time (from): __________Hrs.
Time (To): __________Hrs.
Date:
Type :
Work at height without guardrails
Work at height on fragile surfaces
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Yes-No-NA
Method Statement and Risk Assessment developed, approved and communicated? ☐ ☐ ☐
Area barricaded & proper signage are posted? ☐ ☐ ☐
Qualified and briefed workers? ☐ ☐ ☐
PPE of workers available & inspected as per MS/RA? ☐ ☐ ☐
Tools/Equipment inspected? ☐ ☐ ☐
Safe means of access/ Egress? ☐ ☐ ☐
Lifeline available and inspected? ☐ ☐ ☐
Fragile surface covered / work surface protected? ☐ ☐ ☐
Dimensions of platform and restrain lanyard match safety requirement? ☐ ☐ ☐
Harness with double lanyard provided and its use briefed to workforce? ☐ ☐ ☐
Harness anchorage point checked? ☐ ☐ ☐
Load bearing capacity of anchoring point checked? ☐ ☐ ☐
Load bearing capacity of fragile service checked? ☐ ☐ ☐
Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐
Others ( Specify) ☐ ☐ ☐
4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):
5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature : Time:
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HSE WARNING LETTER-DISCIPLINARY NOTICE Form # HSEQ - HSEWL Rev 6.doc
1st Warning 0 Ref. No. ______________
2nd Warning 0
3rd Warning 0
4th Warning 0 Date: ________________
Employee’s Name : ______________________________________ M.B No. : __________
Occupation : _____________________________________________________________________
Location / Project Site: _____________________________________________________________________
You have committed the following HSE violation/s:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….….
The employee is hereby warned that if the violation is repeated further disciplinary action can be
taken as per the company Code of Conduct.
ORIGINATOR APPROVED BY (MANAGER IN CHARGE / ARABTEC HSEQ & ORG. RISK Manager)
Name: _______________________________ Name: _____________________________
Designation: _______________________________ Designation: _____________________________
Signature:
_______________________________ Signature:
_____________________________
Employee Acknowledgement:
I the undersigned have received this Safety warning letter / disciplinary notice and I admit that I have understood the contents.
0 Received on: ………………………….. (Date) Signature: ………………………………..…..
WORK AT HEIGHT PERMIT Form # HSEQ - WHP Rev.docx
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Detail of Surroundings:
Permit Validity:
Time (from): __________Hrs.
Time (To): __________Hrs.
Date:
Type :
Work at height without guardrails
Work at height on fragile surfaces
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Yes-No-NA
Method Statement and Risk Assessment developed, approved and communicated? ☐ ☐ ☐
Area barricaded & proper signage are posted? ☐ ☐ ☐
Qualified and briefed workers? ☐ ☐ ☐
PPE of workers available & inspected as per MS/RA? ☐ ☐ ☐
Tools/Equipment inspected? ☐ ☐ ☐
Safe means of access/ Egress? ☐ ☐ ☐
Lifeline available and inspected? ☐ ☐ ☐
Fragile surface covered / work surface protected? ☐ ☐ ☐
Dimensions of platform and restrain lanyard match safety requirement? ☐ ☐ ☐
Harness with double lanyard provided and its use briefed to workforce? ☐ ☐ ☐
Harness anchorage point checked? ☐ ☐ ☐
Load bearing capacity of anchoring point checked? ☐ ☐ ☐
Load bearing capacity of fragile service checked? ☐ ☐ ☐
Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐
Others ( Specify) ☐ ☐ ☐
4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):
5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature : Time:
OFFICE INSPECTION Form # HSEQ - Form 1 Rev 2.docx
Project Information
Project Name: Office No.
Location: Contact Person:
Company Name: Date:
Sr. Description Yes No N/A Comments
1. Emergency exit signs are available in right locations
2. Fire alarms and fire extinguishers are visible and accessible.
3. Fire doors (e.g. in stairways) are kept closed unless equipped with automatic closing device
4. Fire extinguishers are serviced regularly
5. Corridors and stairways are kept free of obstruction
6. Fire escape/ evacuation plan available and posted
7. First aid box available
8. Floor surfaces are kept dry and free of slip hazards
9. Electrical cords and plugs are in good condition with proper Grounding
10. Kitchen equipment checked
11. Fire blanket available in the pantry
12. Heat detector available in the pantry
13. Toilets floor clean and dry
14. Are staff trained to use Fire Extinguishers
15. Hand wash/ soap solution available in the toilet
16. Civil Defense or Authority approval
17. Others if any:
Remarks:
Inspected By: Signature:
Reviewed By Project Manager/HSE Manager Signature:
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4. Smoking prevention, controls and arrangements within the Project
5. Hot Works activity controls
(Grinding, Welding, Cutting etc.)
6. Waste disposal: Combustible materials controlled and disposed of correctly.
(E.g. paper, cardboard plastics or wood.)
7. Storage of Flammable Gas within the project
(Acetylene, propane, butane, LPG etc.)
8. Flammable or highly flammable materials or substances on site and point of use.
(e.g. solvents, paints, adhesives, aerosols etc.)
9. Steps to reduce the potential sources of oxygen to a fire.
10. Any operations (or proposed) that may affect the Fire risk assessment
11. Clear access to electrical components and equipment.
12. Suspended ceilings within temporary buildings
(Offices, cabins etc.)
13. Alterations to structure and installations designed to prevent fire spread
14. Arson Prevention
(including security)
15. Smoke/heat detectors installed in high risk areas
16. Fire call points (break glass) installation.
17. Audible/visual fire alarms.
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HSE INDUCTION Form # HSEQ - HSEI Rev 2 -.doc
HSE INDUCTION
(Workers)
Name: _________________________________ Trade: ____________________________
M.B. No./Company Name : ________________
Date of Joining: __________________________
SL. N SUBJECT ON INDUCTION PREVIOUS SAFETY EXPOSURE FURTHER SAFETY TRAINING NEED ANALYSIS
1. Introduction Safety Requirements
2. Working Safety is of Primary Importance
3. General Safety Rules
4. Basic Safety Requirements
5. House Keeping
6. Health, Hygiene & Welfare Facilities
7. Fire Extinguisher / Fire Fighting
8. Emergency Procedure
9. Safety Violations & Penalty
10. Safety Award
11. Manual Handling
Induction Given By: Name: ___________________________
Designation: ___________________________
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25 Demolition of existing concrete structures Risk Assessment Templates.docx
Project Name: xxx
RA Ref No.: xxx
RA compilation Date: Review date:
Date:
Compiled by:
Reviewed by:
Approved by:
Overall Task Details
Use of mechanical breakers – excavator – for demolition of concrete structure Relevant Applicable MAS:
• 00940 – Plant Operators; Additional Training required:
NOC’s Required for task:
RISK SCORE CALCULATOR
Use the Risk Score Calculator to Determine the Level of Risk of each Hazard
What would be the
CONSEQUENCE
of an occurrence be? What is the LIKELIHOOD of an occurrence? Hierarchy of Controls
Frequent/Almost certain (5)
Continuous or will happen frequently Often (4)
6 to 12 times a year Likely (3)
1 to 5 times a year Possible (2)
Once every 5 years Rarely (1)
Less than once every 5 years Can the hazard be Eliminated or removed from the work place?
Catastrophic (5)
Multiple Fatalities High 25 High 20 High 15 Medium 10 Medium 5 Can the product or process be substituted for a less hazardous alternative?
Serious (4)
Class 1 single fatality High 20 High 16 High 12 Medium 8 Low 4 Can the hazard be engineered away with guards or barriers?
Moderate (3)
Class2 (AWI or LTI) or Class 1 Permanently disabling effects High 15 High 12 Medium 9 Medium 6 Low 3 Can Administration Controls be adopted
I.e. procedures, job rotation etc.
Minor (2)
Medical attention needed, no work restrictions. MTI Medium10 Medium 8 Medium 6 Low 4 Low 2 Can Personal Protective Equipment & Clothing be worn to safe guard against hazards?
Insignificant (1)
FAI Medium10 Medium 4 Low 3 Low 2 Low 1
No Specific Task Step
(In sequence of works) Hazard Details Consequence/Risk Initial Risk Rating Control Measures Residual Risks Additional Control Measures RR
L C RR
1 Plant checks on arrival to site
PRIOR TO SITE ACCESS • Use of heavy plant for demolition; • Unauthorized operation of the plant resulting in incident;
• Failure due to use of un-certificated plant;
3 4 12
HIGH i. All plant to be Third Party Certificated by a DM approved inspector, documentation available on arrival to site;
ii. Operators to have in-date Third Party certificate by approved body, available for review on arrival to site;
iii. Visual inspection of plant undertaken by competent person; Documentation unavailable for review Plant quarantined until evidence provided Low
2 Demolition of concrete structure • Excavator breaker operation
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• Operator visibility; • Incident due to use of defective plant or associated equipment;
• Plant reversing – risk of serious injury to pedestrians;
• Unauthorized use of plant by untrained personnel;
• Collision with plant and live traffic within site boundary;
• Workers struck by working plant, very high risk of fatality;
• Noise;
• Exposed rebar – risk of injury;
• Possible contamination of asbestos in structure;
• Proximity to public areas;
4 4 16 HIGH i. Demolition Method statement to be submitted and adhered to. Demolition to be undertaken in a sequential, controlled
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Project Information
Project Name: Office No.
Location: Contact Person:
Company Name: Date:
Sr. Description Yes No N/A Comments
1. Emergency exit signs are available in right locations
2. Fire alarms and fire extinguishers are visible and accessible.
3. Fire doors (e.g. in stairways) are kept closed unless equipped with automatic closing device
4. Fire extinguishers are serviced regularly
5. Corridors and stairways are kept free of obstruction
6. Fire escape/ evacuation plan available and posted
7. First aid box available
8. Floor surfaces are kept dry and free of slip hazards
9. Electrical cords and plugs are in good condition with proper Grounding
10. Kitchen equipment checked
11. Fire blanket available in the pantry
12. Heat detector available in the pantry
13. Toilets floor clean and dry
14. Are staff trained to use Fire Extinguishers
15. Hand wash/ soap solution available in the toilet
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Reviewed By Project Manager/HSE Manager Signature:
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HSE INDUCTION Form # HSEQ - HSEI Rev 2 -.doc
HSE INDUCTION
(Workers)
Name: _________________________________ Trade: ____________________________
M.B. No./Company Name : ________________
Date of Joining: __________________________
SL. N SUBJECT ON INDUCTION PREVIOUS SAFETY EXPOSURE FURTHER SAFETY TRAINING NEED ANALYSIS
1. Introduction Safety Requirements
2. Working Safety is of Primary Importance
3. General Safety Rules
4. Basic Safety Requirements
5. House Keeping
6. Health, Hygiene & Welfare Facilities
7. Fire Extinguisher / Fire Fighting
8. Emergency Procedure
9. Safety Violations & Penalty
10. Safety Award
11. Manual Handling
Induction Given By: Name: ___________________________
Designation: ___________________________
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• NDRC pits;
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Project Name: xxx
RA Ref No.: xxx
RA compilation Date: Review date:
Date:
Compiled by:
Reviewed by:
Approved by:
Overall Task Details
Use of mechanical breakers – excavator – for demolition of concrete structure Relevant Applicable MAS:
• 00940 – Plant Operators; Additional Training required:
NOC’s Required for task:
RISK SCORE CALCULATOR
Use the Risk Score Calculator to Determine the Level of Risk of each Hazard
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CONSEQUENCE
of an occurrence be? What is the LIKELIHOOD of an occurrence? Hierarchy of Controls
Frequent/Almost certain (5)
Continuous or will happen frequently Often (4)
6 to 12 times a year Likely (3)
1 to 5 times a year Possible (2)
Once every 5 years Rarely (1)
Less than once every 5 years Can the hazard be Eliminated or removed from the work place?
Catastrophic (5)
Multiple Fatalities High 25 High 20 High 15 Medium 10 Medium 5 Can the product or process be substituted for a less hazardous alternative?
Serious (4)
Class 1 single fatality High 20 High 16 High 12 Medium 8 Low 4 Can the hazard be engineered away with guards or barriers?
Moderate (3)
Class2 (AWI or LTI) or Class 1 Permanently disabling effects High 15 High 12 Medium 9 Medium 6 Low 3 Can Administration Controls be adopted
I.e. procedures, job rotation etc.
Minor (2)
Medical attention needed, no work restrictions. MTI Medium10 Medium 8 Medium 6 Low 4 Low 2 Can Personal Protective Equipment & Clothing be worn to safe guard against hazards?
Insignificant (1)
FAI Medium10 Medium 4 Low 3 Low 2 Low 1
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L C RR
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• Failure due to use of un-certificated plant;
3 4 12
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2 Demolition of concrete structure • Excavator breaker operation
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• Plant reversing – risk of serious injury to pedestrians;
• Unauthorized use of plant by untrained personnel;
• Collision with plant and live traffic within site boundary;
• Workers struck by working plant, very high risk of fatality;
• Noise;
• Exposed rebar – risk of injury;
• Possible contamination of asbestos in structure;
• Proximity to public areas;
4 4 16 HIGH i. Demolition Method statement to be submitted and adhered to. Demolition to be undertaken in a sequential, controlled
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Access of rig and delivery vehicles to work areas
Siting and setting up of piling rig
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Rebar cage fabrication
Pile case and rebar cage lifting operations
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• Gas;
• Telecoms;
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PRE-START BRIEFING Form # HSEQ - PSB Rev 2 -.docx
Project Information:
Project Name:
Location: Supervisor :
Company name : Date:
Task Description:
Before work starts, the following must be in place
Induction Supervision Test Certificates Communication in same language Method Statement Risk Assessment Permit To Work Area Lighting
SELECT HAZARDS SELECT CONTROLS
( Tick to identify the controls in place)
Fall from height Training Access Ladder Access Handrail Edge Protection Secure Ladder Adequate Work Platform Guards for Openings Safety Harness Life Lines
Others( Specify)
Manual Handling Training Check Weight Mechanical Aids Access Route Team Lifting Wrong method Right Method
Power tools Training Color code inspection tag Check Cable Wheel guards Safe plug & sockets Cable Protection Proper Scaffold Cable Overhead Rotatory part guards
Scaffold Scaffold Tag Edge Protection Check Overhead works Access Ladder Adequate Work Platform Weather condition Out riggers Ladder 3 feet above platform Safety Harness
SELECT HAZARDS SELECT CONTROLS
( Tick to identify the controls in place)
Risk Assessment
Lifting Plan Tag Lines Lifting points / hooks Banks man Load stability Check Lifting gear Examination /Inspection Sharp edges protected
Lifting operations Weather/ Wind Speed Ground conditions Exclusion zone Communication Loading/ unloading vehicles Spreader Beams Check Ground conditions Check outriggers Others
Fire Fire Extinguisher Fire Hose Fire Exit Assembly point others
Slip/Trip Clean before you go Barricade the waste Waste Management Clean Access Housekeeping Clean liquid spillage Access signs Maintain access/ Egress
PPE
Safety Harness
Safety Helmet Coveralls Hi vis Jacket Safety Shoe Face Shield Ear Protection
Dust mask Respiratory Equipment Life line/ harness anchorage Hand Gloves Goggles/ Glass
Pre start Briefing done by: Signature:
Reviewed By HSE Manager/ In charge: Signature:
FIRE PREVENTION REQUIREMENTS Form # HSEQ - Rev 2.docx
Code of Practice
C.O.P # 01
Fire Prevention Requirements
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Rev. 01, Mar 23
SUB CONTRACTORS HSE CHECKLIST Form # HSEQ - SPSC Rev 2 -.docx
1. Project Information:
Project Name: Checklist No.:
Sub-Contractor/Company:
Date:
2. Task Details:
Description of Task:
Location / Area :
Number of Workers:
Task Duration:
Time (from): _______Hrs.
Time (To): __________Hrs.
Date:
3. Prerequisites:
Checks Yes-No-NA Checks Yes-No-NA
Safety induction done. ☐ ☐ ☐
Safety tool box talk done. ☐ ☐ ☐
Method statement/Risk assessment in place. ☐ ☐ ☐
Training on Risk Assessment/ Method Statement done ☐ ☐ ☐
Job Safety Analysis done. ☐ ☐ ☐
3 Month Safety Look Ahead in place ☐ ☐ ☐
Permit to Work obtained ☐ ☐ ☐
Site Supervisor available ☐ ☐ ☐
PPE Available ☐ ☐ ☐
Working area is well lighted ☐ ☐ ☐
Tools and equipment inspected and tagged ☐ ☐ ☐
Unsafe conditions rectified ☐ ☐ ☐
Pre-Start Checks completed ☐ ☐ ☐
Emergency procedures communicated ☐ ☐ ☐
Unauthorized workers are cleared from the area.
☐ ☐ ☐
Other ( Specify): ☐ ☐ ☐
4. Acknowledgement by Sub-Contractor:
☐ Acknowledge that all above precautions/ controls measures have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Date /Time:
Signature: Date /Time
STORE INSPECTION Form # HSEQ - Form 2 Rev 2.docx
Project Information
Project Name: Store No.
Location: Contact Person:
Company Name: Arabtec Construction LLC. Date:
Sr. Description Yes No N/A Comments
1. Is access to stores are restricted to authorized personnel only?
2. Are there clear spaces around racks and stacks of stored materials and are adequate gangways provided between them?
3. Are stacks and storage kept clear of light fittings and hot surfaces?
4. Are all stocks of flammable liquids kept in purpose-built flammable storage liquid stores?
5. Are storage areas generally cleaned and tidy?
6. Are flammable liquids kept away from all possible sources of ignition?
7. Emergency exit signs are available in right locations
8. Smoke detectors/fire alarm are visible and accessible.
9. Fire extinguishers are available are serviced regularly
10. Are free standing shelves and cupboards secured for stability?
11. Are heavy items stored at a suitable height?
12. Are chemical containers used for storage suitable and clearly labelled?
13. Is there adequate light in the storage area?
14. Are all small loose items secured in appropriate storage?
15. Are warning notices, prohibiting smoking and naked lights prominently displayed?
16. Others if any:
Remarks:
Inspected by: Signature:
Reviewed by Project Manager/HSE Manager Signature:
WITNESS STATEMENT FORM.docx
PROJECT:
LOCATION: DATE:
I (name)_____________________________________would like provide my statement as follows on.
I hereby acknowledge that the above statement are true to the best of my recollection, and that these are my very own written down by m myself s others _________Name and Signature________
Name : ____________________________ Signature: ______________________
Position: _________________________________________Date:_________________
PROJECT LEADER INCIDENT BRIEFING Form # HSEQ - PLIB Rev 2 -.docx
1. Project Information:
Project Name: Click here to enter text.
Report No.: Click here to enter text.
Project Location: Click here to enter text.
Property No.: Click here to enter text.
☐ Fatality ☐ Major Injury ☐ Minor Injury ☐ Property Damage ☐ Environmental ☐ Other
2. Describe the Incident in detail:
Answer who, what, why, where, when & how in this section: (Attach additional pages if required)
3. Incident Root Causes:
Describe direct, indirect & root cause: (Attach additional pages if required)
4. Key Corrections Taken Immediately after the Incident:
Attach additional pages if more space is required:
5. Key Corrective Actions to Prevent Recurrence:
Describe the corrective actions with timeframe: (Attach additional pages if required)
Corporate Office Remarks:
LIFT SHAFT ENTRY PERMIT Form # HSEQ - LSEP Rev 2 -.docx
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Detail of Surroundings:
Permit Validity:
Time (from): __________Hrs.
Time (To): __________Hrs.
Date:
3. Control Measures: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Method statement & Risk assessment developed, approved & communicated? ☐ ☐ ☐
Availability of rescue procedure and equipment? ☐ ☐ ☐
Operatives are trained and competent? ☐ ☐ ☐
Workplace appropriately illuminated ☐ ☐ ☐
Any high risk activity associated that requires PTW (i.e. hot work, CSE)? ☐ ☐ ☐
Forced ventilation provided? ☐ ☐ ☐
Are all necessary Permit approved and displayed at work location? ☐ ☐ ☐
Means of communication available? (Mobile, radio etc.) ☐ ☐ ☐
Safe access / Working Platform provided? ☐ ☐ ☐
Mandatory/specific good condition PPEs are available ☐ ☐ ☐
Availability of barricades/protection to prevent unauthorized or accidental entry? ☐ ☐ ☐
Life Line provided? ☐ ☐ ☐
Warning signs posted? ☐ ☐ ☐
Fall Protection equipment (e.g. full body harness) available? ☐ ☐ ☐
Availability of Fall protection arrangement? ☐ ☐ ☐
Other(s): ☐ ☐ ☐
Adequate Lighting provided? ☐ ☐ ☐
☐ ☐ ☐
4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Time
Comments (if any):
5. Authorization (PM/CM):
Name: Designation:
Signature: Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time:
LIVE ELECTRICAL WORK PERMIT Form # HSEQ - LEP Rev 2.docx
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Location / Area :
Panel No : Voltage:
Permit Validity:
Time (from): _______Hrs.
Time (To): __________Hrs.
Date:
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
No: Checks Yes-No-NA Checks Yes-No-NA
ENERGIZATION (“Power On”) ISOLATION (“Power Off”)
1. Safety tool box briefing done. ☐ ☐ ☐
Method statement/Risk assessment in place. ☐ ☐ ☐
2. Authorized personnel / operators available. ☐ ☐ ☐
Authorized personnel / operators available. ☐ ☐ ☐
3. Method statement/Risk assessment in place. ☐ ☐ ☐
Adjacent live areas protected. ☐ ☐ ☐
4. Safety Barriers in place and safety signage Displayed. ☐ ☐ ☐
PPE available, high voltage rubber gloves, Safety goggles and floor mat. ☐ ☐ ☐
5. Working area is well lighted. ☐ ☐ ☐
Isolation/Lock-out in place. ☐ ☐ ☐
6. Electrical instruments are available for any Purpose. ☐ ☐ ☐
Electrical circuits “proved” by calibrated Instrument and found out to be no power. ☐ ☐ ☐
7. Correct PPE available, high voltage rubber Gloves, safety goggles and floor mat. ☐ ☐ ☐
Unauthorized workers are cleared from the Area. ☐ ☐ ☐
8. Approved WIR for installation, testing and Termination are attached to the permit. ☐ ☐ ☐
Standby operatives in the event of contact With live circuits. ☐ ☐ ☐
9. Emergency light (Flashlight) available. ☐ ☐ ☐
Emergency light (Flashlight) available. ☐ ☐ ☐
10. Is live work absolutely necessary? ☐ ☐ ☐
Emergency response plan available ☐ ☐ ☐
11. Unauthorized workers are cleared from the area.
☐ ☐ ☐
Other ( Specify): ☒ ☐ ☐
12. Power cable route from panel board to plant & equipment has been checked ☐ ☐ ☐
13 Emergency response plan available ☐ ☐ ☐
14 Other ( Specify): ☐ ☐ ☐
4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):
5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time:
MOBILE PLANT REGISTER Form # HSEQ - MPR Rev 3.docx
Project Information
Project Name:
Date: Location:
Sr. Equipment type / Name Registration No & Exp Date Company Name
Operator Name / Mb. No Operator Third party competency certificate expiry date Operator License expiry date Equipment & Plant 3rd Party Inspection Certificate expiry date SWL / Capacity Signalman /Rigger name & TPC Exp Comment
1
2
3
4
5
6
7
8
9
10.
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge: Signature:
LABOR ACCOMMODATION CHECKLIST Form # HSEQ - LAC Rev 2.docx
Accommodation Name: Date :
Accommodation Location: Time :
SN Description Yes NO N/A Observation Control
Measures Due Date
ACCESS AND EGRESS
1 Is there segregation between vehicles/ pedestrians
2 Is entry to inside camp restricted to workforce only? How is this controlled
3 Is the entrance well lit
4 Is the entrance free from water pooling
GENERAL HOUSEKEEPING
1 Are there adequate dustbins available? Are they covered
2 Is garbage disposed of on a regular basis?
3 Are toilets wash areas cleaned regular?
4 Is there adequate water for toilet and bath
5 Are water tanks kept covered at all times
6 Is soap and hand towels available?
7 Is bathroom area cleaned on a regular basis and kept dry and non-slippery
8 Is the water tank cleaned on a regular basis
9 Is the laundry area electrical & connections/ wires are in good condition.
10 Is the laundry area kept clean and dry
11 Is the tumble dryer filters cleaned frequently to prevent overheating
SEPTIC TANKS
1 Is the camp on main drainage?
2 If not are septic tanks provided?
3 Are septic tanks fitted with overflow alarm if not how are they prevented from overflowing
4 If septic tank in ground is it in a membrane?
5 If above ground is it protected from being hit by vehicular traffic?
FOOD PREPARATION AREA
1 Is the area kept clean and tidy
2 Are food preparation areas cleaned and free from cracks
3 Are signs for "No smoking" being posted
4 Food waste storage area is cleaned, odour free. Flies area controlled
5 Floor drains are provided in sink area
6 All refrigerators and freezers are working at correct temperatures Refrigerators 1c0 to 4c0
Freezers -14c0 to -18c0
7 Are there temp gauges fitted?
8 Are these temperatures recorded?
9 The Dining and Kitchen areas have an overall clean, tidy and well maintained appearance
10 LPG cylinders are of good conditions (free of damages)
11 Is storage of LPG satisfactory under shed & outside kitchens with no flammable materials nearby
12 Are Piping not perished
13 Are firefighting equipment provided in kitchen area?
LIVING QUARTERS
1 Are Ventilation working well
2 Is lighting suitable
3 Are Emergency numbers being posted in each room
4 Are emergency procedures posted in each room
5 Are Electrical sockets in good condition not damaged & no bare wires are placed in sockets
6 Are sockets overloaded
7 ELCB is provided checks carried out and recorded by
INCIDENT INVESTIGATION REPORT Form # HSEQ - IIR Rev 9 -.docx
INCIDENT INVESTIGATION REPORT
(To be submitted to the HSEQ Corporate Office within 7 days of incident.)
1. Project Information:
Project Name: Click here to enter text.
Report No.: Click here to enter text.
Project Location: Click here to enter text.
Property No.: Click here to enter text.
☐ Fatality ☐ Major Incident ☐ Minor Incident
2. Describe the Incident in detail:
Answer who, what, why, where, when & how in this section: (Attach additional pages if required)
Click here to enter text.
☐ Photos Attached
3. Incident Root Causes:
Describe direct, indirect & root cause: (Attach additional pages if required)
Click here to enter text.
4. Key Corrective Actions to Prevent Recurrence:
Describe the corrective actions with timeframe: (Attach additional pages if required)
Click here to enter text.
5. Key Corrections Taken Immediately after the Incident:
Attach additional pages if more space is required:
Click here to enter text.
6. Witnesses:
I declare that I witnessed the incident and the information provided above is true, correct and complete.
No. Name Designation Signature Date
1. Click here to enter text.
Click here to enter text.
Click here to enter text.
2. Click here to enter text.
Click here to enter text.
Click here to enter text.
7. Incident Information:
Initial Incident Report No.: Click here to enter text.
Date Reported: Click here to enter text.
Date of Incident: Click here to enter text.
Time of Incident: Click here to enter text.
Type of Incident: ☐ Near Miss
☐ Major Environmental Incident
☐ Serious Dangerous Occurrence
☐ Equipment / Property Damage
☐ Medical Treatment Case (MTC)
☐ Restricted Work Case (RWC)
☐ Lost Workday Case (LWC)
☐ Serious Occupational Illness/Disease
☐ Class 1 Injuries
☐ Permanent Partial Disability (PPD)
☐ Permanent Total Disability (PTD)
☐ Fatality (F)
Recordkeeping: ☐ Reportable ☐ Recordable
Incident Location on Site: Click here to enter text.
Applicable Reports: ☐ Police
☐ Medical
☐ Other (Specify)
Click here to enter text.
Attached: ☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
8. Injured Person’s Personal Details:
In case of an incident with more than one injured person, complete the information for each person using separate forms.
Name: Click here to enter text.
Occupation: Click here to enter text.
Company: Click here to enter text.
MB / Oracle No.: Click here to enter text.
Nationality: Click here to enter text.
Date of Birth: Click here to enter text.
Passport Number: Click here to enter text.
Length of Service: Click here to enter text.
Gender: ☐ Male ☐ Female
Labour Card No.: Click here to enter text.
9. Incident Causes Details: To be supported with factual evidence
Immediate Cause
(Unsafe Acts) ☐ Failure to secure
☐ Failure to warn
☐ Removing / Defeating Safety Devices
☐
OFFICE PORTA CABIN INSPECTION Form # HSEQ - OPC Rev 2.docx
Project Information
Project Name: Porta Cabin No:
Location: Contact Person:
Company Name: Date :
Sr. Description Yes No N/A Comments
1. Emergency exit signs are available in right locations
2. Fire alarms and fire extinguishers are visible and accessible.
3. Fire doors (e.g. in stairways) are kept closed unless equipped with automatic closing device
4. Fire extinguishers are serviced regularly
5. Corridors and stairways are kept free of obstruction
6. Fire escape/ evacuation plan available and posted
7. First aid box available
8. Floor surfaces are kept dry and free of slip hazards
9. Electrical cords and plugs are in good condition with proper Grounding
10. Kitchen equipment checked
11. Fire blanket available in the pantry
12. Heat detector available in the pantry
13. Toilets floor clean and dry
14. Are staff trained to use Fire Extinguishers
15. Hand wash/ soap solution available in the toilet
16. Civil Defense or Authority approval
17. Others if any:
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge : Signature:
MEDICAL REPORT FORM Form # HSEQ - MRF Rev 3 -.docx
MEDICAL REPORT FORM
Day _____________
Date ____________
Time ____________
To: _________________________________________________________________________________________________________
Dear Sir,
We would kindly request you to give necessary treatment to our following employee who had met with an accident and provide us with your diagnosis.
Name of injured __________________________________________________________ Age ( ) years.
Occupation __________________________________________________________ M.B. No. _______________________________
Date of Accident ____________________________________________ Time of Accident __________________________________
Place of Accident (Project Name) _______________________________ Location _________________________________________
Nature of Accident ____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
First Aider Name: ________________________________ SE Manager/Incharge: ________________________________
Signature: ________________________________ Signature: ________________________________
(If Medical Certificate is attached, this portion is not required.)
MEDICAL REPORT
Nature and extent of Accident / Injury____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Fit for duty___________________________________________________________________________________________________
Unfit for duty_________________________________________________________________________________________________
Remarks_____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature of Medical Officer Date _______________
LIFTING TACKLE VISUAL INSPECTION & REGISTER Form # HSEQ - LTVIR Rev 3.docx
Project Information
Project Name:
Company Name: Date :
ID NO TYPE OF LIFTING GEARS LOCATION VISUAL INSPECTION THIRD PARTY INSPECTION VALID TILL MONTHLY COLOUR CODE
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
☐ OK ☐ Not OK
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge : Signature:
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About
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
• Remote control: Parallel or serial interface.
• Compatible with MAFI CCR system.
• Compatible with IDM8000 CCR.
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
• Easy in configuration using DIP switches.
Technical Specifications
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
Key Features
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
• Remote control: Parallel or serial interface
• Compatible with MAFI CCR system
• Copatiable with IDM8000 CCR
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
Application
• Remote control: Parallel or serial interface.
• Compatible with MAFI CCR system.
• Compatible with IDM8000 CCR.
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
• Easy in configuration using DIP switches.
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