HSE FORMS (COVER PAGE)2 Form # HSEQ - Rev 2.docx
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This document pertains to health, safety, environment, and quality forms from an HSEQ department. The HSEQ department handles forms related to health, safety, environment, and quality assurance. No other details are provided about the specific forms or purpose of the HSEQ department.
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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
(Management of Combustible Materials & Electrical Inspections)
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
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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
(Management of Combustible Materials & Electrical Inspections)
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
☐
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: ___________________________
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: ………………………………..…..
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:
FULL BODY HARNESS INSPECTION RECORD Form # HSEQ - FBHIR Rev 2.docx
Harness Checklist
Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Remarks
Shoulder Straps
Chest & Back Straps
Waist Straps
Back D-Ring
Shoulder Adjustment
Legible Label
Shoulder Straps
Chest & Back Straps
Waist Straps
Leg Straps
Cuts
Burns
Holes
Deterioration
Corrosive/ worn out
Color code
Others (Specify)
Project Information
Project Name: Location:
Company name : Date:
Remarks:
Inspector Name: Signature:
Reviewed By HSE Manager / Incharge Signature:
GENERAL SITE SAFETY RULES Form # HSEQ - Rev 2.docx
Do not take shortcuts. Always follow safe working procedure/methods and instructions.
HAZARDOUS SUBSTANCE CHECKLIST Form # HSEQ - HSC Rev 2 -.docx
Project Information
Project Name:
Location:
Company Name: Date :
Sl. No Description Yes No N/A Comments
1. Properly stored, labeled, ventilated, isolated, Log and suitable signs displayed.
2. Material Data Safety Sheet (MSDS) available, and communicated to concerned personnel.
3. Adequate/ Sufficient firefighting equipment are in place.
4. Emergency escape and breathing apparatus available, tested and in good condition.
5. Hazardous substances containers/drums have eligible labeling and protected from leakages or spillage.
6. Personnel must be trained in chemical handling.
7. Emergency control plan must be made available, spillage control kits must be available.
8. Empty hazardous substances containers, drums and receptacles should be properly maintained and controlled.
9. Expired chemicals are logged, segregated and disposed properly
10. Others Specify
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge : Signature:
CONCRETE PUMP & EXTENSION PIPELINE Form # HSEQ - CPC Rev 2.docx
Project Information
Project Name: Concrete Pump Reg. No:
Location: Operators Name:
Company Name: Date :
Sr. Description Yes No N/A Comments
1. Concrete Pump 3rd Party Certificate & Registration
2. Sonographic test of all pipes
3. Calibration of all the pressure gauges
4. Operator’s Competency Certificate & Driver’s License
5. Safe distance from the edge of the excavation
6. Outrigger pads are free from damage
7. Outriggers are level
8. Reverse alarm and beacon light are operational
9. Whip arrester on the pipes and pump
10. Safe access for concrete mixer to the area (In/Out)
11. Area properly barricaded and signage posted
12. Hydraulic Oil / Diesel Leakage
13. Extension Pipeline - Free from damage
14. Extension Pipeline -Locking pin in every connection
15. Extension Pipeline - Adequately supported & secured
16. Spillage control measure in place
17. Other accessories e.g. spider pacing boom 3rd party certificate
18. Static pumps positioned properly
19. Static pumps – concrete pipes fixed on structure as per design
20. Concrete pipes coupler pins provided
21. Concrete pipes on floor – away from scaffolds/ formworks
22. Competent banks man and supervision provided
23. Others (Specify)
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge : Signature:
Noted by Project Leader Signature:
BEHAVIORAL OBSERVATION Form # HSEQ BO Rev.0.docx
Project Behavioral Observation Form
Process Observed
Works Package
Subcontractor / CName
Date _ _ /_ _ /_ _ Time from ______ to ______ Duration Mins _____
Checklist attached ☐
Video ☐
Photo (s) ☐
Observation Summary (Ref checklist for details)
Safe ☐
Unsafe Acts ☐
Safe ☐
Unsafe conditions ☐
Status:
A. All activities conducted in a safe manner ☐
No negative observations
B. Generally conducted in a safe manner ☐
Some aspects of the process require improvement
C. Partially conducted in a safe manner ☐
One aspect of a task needs improvement
D. Some individual lapses ☐
One person working unsafely part of the time
E. Generally conducted in unsafe manner ☐
More than one person working unsafely
ATC Engineer-in-charge Supervisor
Follow up Action
☐
Analysed by HSE Manager and responsible person _________________
☐
Reported / shown to team observed
☐
Recommended Action
☐
Follow up recommendation
FIRE PREVENTION CHECKLIST Form # HSEQ - FPC Rev 2 -.docx
SR. TITLE YES NO N/A Comments
1 FIRE PROTECTION EQUIPMENT
1.1 Are adequate fire-fighting equipment and sufficient extinguishing agents available and operative at all times?
1.2 Have workers been oriented on their correct use and operation?
1.3 Are portable fire extinguishers of sufficient capacity (at least 20 lbs.) and type available and strategically positioned near hazardous work such that the travel distance to the nearest unit is no greater than 15 meters?
1.4 Are regular checks undertaken to make sure that the equipment is not missing or damaged?
1.5 Is a fully operational yard hydrant/Fire Hose reel system available prior to start of construction (excluding foundation work) and during the entire construction period?
Where street hydrants are not available, are temporary hydrants provided?
1.6 Is a waterline extended as soon as possible behind construction to supplement the Fire Extinguishers placed throughout the construction area?
1.7 Are permanent standpipes extended as close as possible behind construction to allow use in case of fire?
1.8 Are fully operative standpipes (wet risers) installed up to one level below the highest current work level and are sealed by temporary end caps?
1.9 (The following is a less stringent alternative to Item 8 above)
Where construction involves buildings more than 23 meters high, are fully operative standpipes (wet risers) available not less than
3 levels below the highest level under construction.
Where the provision of wet risers does not impede structural work, are they provided to the level below the highest level under construction?
1.10 Are the cabinets containing hose reels and portable fire extinguishers inspected at regular intervals but at least twice a week by competent persons?
1.11 Are hydrants and standpipes including fire water supply system designed and installed in compliance with UAE Fire and Life safety COP and according to the relevant internationally recognized codes and standards, e.g., NFPA, FM, etc.?
1.12 Is the fire water supply at the site available at the required volume and pressure?
1.13 Is storage of any material within 3 meters of fire hydrants/Fire Hose reels strictly prohibited? Is access to the outlets unobstructed?
2 COMPARTEMENTATION / SEGMENTATION YES NO N/A COMMENTS
2.1 Are fire compartments as required by local regulations installed as soon as possible after the removal of formwork?
2.2 Are openings for lift shafts, service ducts and other voids provisionally closed as soon as possible but not later than at the commencement of fit-out work?
3 FIRE PREVENTION : HOT WORK MANAGEMENT YES NO N/A COMMENTS
3.1 Is a “permit to work” system being implemented for all parties engaged in “hot work” of any kind such as but not limited to
– grinding, cutting or welding operations,
– use of blow lamps and torches,
– application of hot bitumen
or any other heat-pro
COLD WORK PERMIT Form # HSEQ - CWP Rev 2.docx
Issue Date: _______________ Permit No: ____________
Permit Requested By: __________________ Company Name: ________________ Permit Accepted By: __________________ Company Name: ________________
Validity From: __________ To: __________
1. Job Location: _____________________________________________________________
2. Job Description: __________________________________________________________
________________________________________________________________________________________________________________________________________________
3 Tools & Materials to be used:
❑Explosive Device ❑Sandblaster ❑Jack hammers
❑Hand Tools ❑Drill ❑Jack hammers
❑Powered Excavation Equipment ❑Powered cutting Saw ❑Ladder/Scaffolding
❑Air Heater ❑LPG Gas ❑Others
4- Details of potential hazards:
❑Falling from height ❑ Material Fall down ❑Skin Exposures
❑Electrocuted ❑ Slip and trip ❑Burn out due to fire/acid etc.
❑Exposure to Eye ❑ Inhalation of any Gas ❑Breathing Problem ❑Others
5- Details of precaution need to be taken:
❑Caution Signage to be placed ❑Proper fixture an erection of Scaffolding/Ladder
❑Excavated Area fencing ❑Electrical Isolation
❑Fire water supply isolation ❑Fire water tanker to be provided
❑Fire Extinguishers to be provided ❑Exhaust fan to be provided
❑Informed security Et Help Desk ❑Other
6- Details of protective equipment to be used or worn:
❑Safety Shoes
❑Safety Helmet
❑Face Shield/Goggle/Glasses
❑Gloves (As per work)
❑Safety harness/Belt/Lifeline
❑Uniform ❑Respiratory Equipment/Dust Mask
❑Chemical Suite/Apron
❑Ear protection
❑Fire Blanket/Protection Sheet
❑Rubber Mat/Ground Fault Interrupter
❑Other
7- Signature of Permit Requestor:
Contact No:-
8- Signature of PTW Acceptor:
Contact No:-
9- Signature of Permit Issuer/HSE Representative:
10- Signature of handover of responsibility between shifts, if needed.
11- Declaration by competent person in -charge of work that work is completed.
12- Signature of Maintenance / works representative ensuring that the work is
completed, site has been checked and that equipment and place may be reinstated / left
Safely isolated.
13- Signature of person issuing the permit / HSE representative which confirms that the
Site has been left in safe condition and the permit is cancelled.
14- Signature of the management representative signing off the permit to work.
REMARKS:-
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
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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
☐
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: ___________________________
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: ………………………………..…..
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:
FULL BODY HARNESS INSPECTION RECORD Form # HSEQ - FBHIR Rev 2.docx
Harness Checklist
Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Sl. No
………. Remarks
Shoulder Straps
Chest & Back Straps
Waist Straps
Back D-Ring
Shoulder Adjustment
Legible Label
Shoulder Straps
Chest & Back Straps
Waist Straps
Leg Straps
Cuts
Burns
Holes
Deterioration
Corrosive/ worn out
Color code
Others (Specify)
Project Information
Project Name: Location:
Company name : Date:
Remarks:
Inspector Name: Signature:
Reviewed By HSE Manager / Incharge Signature:
GENERAL SITE SAFETY RULES Form # HSEQ - Rev 2.docx
Do not take shortcuts. Always follow safe working procedure/methods and instructions.
HAZARDOUS SUBSTANCE CHECKLIST Form # HSEQ - HSC Rev 2 -.docx
Project Information
Project Name:
Location:
Company Name: Date :
Sl. No Description Yes No N/A Comments
1. Properly stored, labeled, ventilated, isolated, Log and suitable signs displayed.
2. Material Data Safety Sheet (MSDS) available, and communicated to concerned personnel.
3. Adequate/ Sufficient firefighting equipment are in place.
4. Emergency escape and breathing apparatus available, tested and in good condition.
5. Hazardous substances containers/drums have eligible labeling and protected from leakages or spillage.
6. Personnel must be trained in chemical handling.
7. Emergency control plan must be made available, spillage control kits must be available.
8. Empty hazardous substances containers, drums and receptacles should be properly maintained and controlled.
9. Expired chemicals are logged, segregated and disposed properly
10. Others Specify
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge : Signature:
CONCRETE PUMP & EXTENSION PIPELINE Form # HSEQ - CPC Rev 2.docx
Project Information
Project Name: Concrete Pump Reg. No:
Location: Operators Name:
Company Name: Date :
Sr. Description Yes No N/A Comments
1. Concrete Pump 3rd Party Certificate & Registration
2. Sonographic test of all pipes
3. Calibration of all the pressure gauges
4. Operator’s Competency Certificate & Driver’s License
5. Safe distance from the edge of the excavation
6. Outrigger pads are free from damage
7. Outriggers are level
8. Reverse alarm and beacon light are operational
9. Whip arrester on the pipes and pump
10. Safe access for concrete mixer to the area (In/Out)
11. Area properly barricaded and signage posted
12. Hydraulic Oil / Diesel Leakage
13. Extension Pipeline - Free from damage
14. Extension Pipeline -Locking pin in every connection
15. Extension Pipeline - Adequately supported & secured
16. Spillage control measure in place
17. Other accessories e.g. spider pacing boom 3rd party certificate
18. Static pumps positioned properly
19. Static pumps – concrete pipes fixed on structure as per design
20. Concrete pipes coupler pins provided
21. Concrete pipes on floor – away from scaffolds/ formworks
22. Competent banks man and supervision provided
23. Others (Specify)
Remarks:
Inspected By: Signature:
Reviewed By HSE Manager / In charge : Signature:
Noted by Project Leader Signature:
BEHAVIORAL OBSERVATION Form # HSEQ BO Rev.0.docx
Project Behavioral Observation Form
Process Observed
Works Package
Subcontractor / CName
Date _ _ /_ _ /_ _ Time from ______ to ______ Duration Mins _____
Checklist attached ☐
Video ☐
Photo (s) ☐
Observation Summary (Ref checklist for details)
Safe ☐
Unsafe Acts ☐
Safe ☐
Unsafe conditions ☐
Status:
A. All activities conducted in a safe manner ☐
No negative observations
B. Generally conducted in a safe manner ☐
Some aspects of the process require improvement
C. Partially conducted in a safe manner ☐
One aspect of a task needs improvement
D. Some individual lapses ☐
One person working unsafely part of the time
E. Generally conducted in unsafe manner ☐
More than one person working unsafely
ATC Engineer-in-charge Supervisor
Follow up Action
☐
Analysed by HSE Manager and responsible person _________________
☐
Reported / shown to team observed
☐
Recommended Action
☐
Follow up recommendation
FIRE PREVENTION CHECKLIST Form # HSEQ - FPC Rev 2 -.docx
SR. TITLE YES NO N/A Comments
1 FIRE PROTECTION EQUIPMENT
1.1 Are adequate fire-fighting equipment and sufficient extinguishing agents available and operative at all times?
1.2 Have workers been oriented on their correct use and operation?
1.3 Are portable fire extinguishers of sufficient capacity (at least 20 lbs.) and type available and strategically positioned near hazardous work such that the travel distance to the nearest unit is no greater than 15 meters?
1.4 Are regular checks undertaken to make sure that the equipment is not missing or damaged?
1.5 Is a fully operational yard hydrant/Fire Hose reel system available prior to start of construction (excluding foundation work) and during the entire construction period?
Where street hydrants are not available, are temporary hydrants provided?
1.6 Is a waterline extended as soon as possible behind construction to supplement the Fire Extinguishers placed throughout the construction area?
1.7 Are permanent standpipes extended as close as possible behind construction to allow use in case of fire?
1.8 Are fully operative standpipes (wet risers) installed up to one level below the highest current work level and are sealed by temporary end caps?
1.9 (The following is a less stringent alternative to Item 8 above)
Where construction involves buildings more than 23 meters high, are fully operative standpipes (wet risers) available not less than
3 levels below the highest level under construction.
Where the provision of wet risers does not impede structural work, are they provided to the level below the highest level under construction?
1.10 Are the cabinets containing hose reels and portable fire extinguishers inspected at regular intervals but at least twice a week by competent persons?
1.11 Are hydrants and standpipes including fire water supply system designed and installed in compliance with UAE Fire and Life safety COP and according to the relevant internationally recognized codes and standards, e.g., NFPA, FM, etc.?
1.12 Is the fire water supply at the site available at the required volume and pressure?
1.13 Is storage of any material within 3 meters of fire hydrants/Fire Hose reels strictly prohibited? Is access to the outlets unobstructed?
2 COMPARTEMENTATION / SEGMENTATION YES NO N/A COMMENTS
2.1 Are fire compartments as required by local regulations installed as soon as possible after the removal of formwork?
2.2 Are openings for lift shafts, service ducts and other voids provisionally closed as soon as possible but not later than at the commencement of fit-out work?
3 FIRE PREVENTION : HOT WORK MANAGEMENT YES NO N/A COMMENTS
3.1 Is a “permit to work” system being implemented for all parties engaged in “hot work” of any kind such as but not limited to
– grinding, cutting or welding operations,
– use of blow lamps and torches,
– application of hot bitumen
or any other heat-pro
COLD WORK PERMIT Form # HSEQ - CWP Rev 2.docx
Issue Date: _______________ Permit No: ____________
Permit Requested By: __________________ Company Name: ________________ Permit Accepted By: __________________ Company Name: ________________
Validity From: __________ To: __________
1. Job Location: _____________________________________________________________
2. Job Description: __________________________________________________________
________________________________________________________________________________________________________________________________________________
3 Tools & Materials to be used:
❑Explosive Device ❑Sandblaster ❑Jack hammers
❑Hand Tools ❑Drill ❑Jack hammers
❑Powered Excavation Equipment ❑Powered cutting Saw ❑Ladder/Scaffolding
❑Air Heater ❑LPG Gas ❑Others
4- Details of potential hazards:
❑Falling from height ❑ Material Fall down ❑Skin Exposures
❑Electrocuted ❑ Slip and trip ❑Burn out due to fire/acid etc.
❑Exposure to Eye ❑ Inhalation of any Gas ❑Breathing Problem ❑Others
5- Details of precaution need to be taken:
❑Caution Signage to be placed ❑Proper fixture an erection of Scaffolding/Ladder
❑Excavated Area fencing ❑Electrical Isolation
❑Fire water supply isolation ❑Fire water tanker to be provided
❑Fire Extinguishers to be provided ❑Exhaust fan to be provided
❑Informed security Et Help Desk ❑Other
6- Details of protective equipment to be used or worn:
❑Safety Shoes
❑Safety Helmet
❑Face Shield/Goggle/Glasses
❑Gloves (As per work)
❑Safety harness/Belt/Lifeline
❑Uniform ❑Respiratory Equipment/Dust Mask
❑Chemical Suite/Apron
❑Ear protection
❑Fire Blanket/Protection Sheet
❑Rubber Mat/Ground Fault Interrupter
❑Other
7- Signature of Permit Requestor:
Contact No:-
8- Signature of PTW Acceptor:
Contact No:-
9- Signature of Permit Issuer/HSE Representative:
10- Signature of handover of responsibility between shifts, if needed.
11- Declaration by competent person in -charge of work that work is completed.
12- Signature of Maintenance / works representative ensuring that the work is
completed, site has been checked and that equipment and place may be reinstated / left
Safely isolated.
13- Signature of person issuing the permit / HSE representative which confirms that the
Site has been left in safe condition and the permit is cancelled.
14- Signature of the management representative signing off the permit to work.
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PROJECT LEADER INCIDENT BRIEFING Form # HSEQ - PLIB Rev 2 -.docx
PROJECT LEADER INCIDENT BRIEFING Form # HSEQ - PLIB Rev 2 -.docx
LIFT SHAFT ENTRY PERMIT Form # HSEQ - LSEP Rev 2 -.docx
LIFT SHAFT ENTRY PERMIT Form # HSEQ - LSEP Rev 2 -.docx
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LIVE ELECTRICAL WORK PERMIT Form # HSEQ - LEP Rev 2.docx
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CONCRETE PUMP & EXTENSION PIPELINE Form # HSEQ - CPC Rev 2.docx
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