2.

0 HSE Forms
2.1 HNE-HSE-F-01 Contractors Safety Information
2.2 HNE-HSE-F-02 Tool Box Talk
2.3 HNE-HSE-F-03 HSE Meeting Report
2.4 HNE-HSE-F-04 Safety Observation Report
2.5 HNE-HSE-F-05 Environment Incident Report
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2.6 HNE-HSE-F-06 Corrective Action Request

2.7 HNE-HSE-F-07 Course Attendance Sheet
2.8 HNE-HSE-F-08 Training Calendar
2.9 HNE-HSE-F-09 Fire Extinguisher Inspection Report
2.10 HNE-HSE-F-10 Safety Violation Notice
2.11 HNE-HSE-F-11 Mobile Crane Entry Permit
2.12 HNE-HSE-F-12 Hot Work Permit
2.13 HNE-HSE-F-13 Confined Space Entry Permit
2.14 HNE-HSE-F-14 Electrical Isolation Permit
2.15 HNE-HSE-F-15 Excavation Permit
2.16 HNE-HSE-F-16 PTW Register
2.17 HNE-HSE-F-17 Incident Notification Form
2.18 HNE-HSE-F-18 Incident Report
2.19 HNE-HSE-F-21 Incident Investigation Report
2.20 HNE-HSE-F-20 Suggestion and Near Miss Card
2.21 HNE-HSE-F-21 Safety Violation Register
2.22 HNE-HSE-F-22 First Aid Register
2.23 HNE-HSE-F-23 Site HSE Checklist
2.24 HNE-HSE-F-24 Emergency Contact

2.25 HNE-HSE-F-25 HSE Induction Record

2.26 HNE-HSE-F-26 Document Distribution record

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 HNE SAFETY DECLARATION

This information applies to HNE and others sub contractors under their control engaged in
carrying out work on the project and premises.
It is HNE’s intention to secure a high standard of health safety and environment compliance in
all our areas of control.
 HNE will comply with national and local health and safety legislation and codes of
practices and Client / Consultant HSE rules / HSE Plan whilst on site.
 HNE submit risk assessments and method statements for all activities and get the Client /
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Consultant approval before carrying out the work. HNE will adhere to the identified
control measures while executing the work activity.
 When changes in health and safety controls may be necessary, such changes will be
informed to the Client / Consultant HSE personnel. This will cover for example hazards,
restricted access areas, fire precautions, emergency response, first aid facilities, accident
reporting, welfare facilities, smoking restrictions, segregation of work activities, any
other issues affecting health and safety.
 HNE / CONTRACTOR will be responsible and accountable for all accidents
involving their employees and equipment. All accidents will be notified to Client /
Consultant HSE personnel as per the Client / Consultant HSE Plan and Policy.
 The work area should be left tidy and secure, not only on completion of the work but each
time the Contractors leaves project premises.
 All Contractors must familiarise themselves with the Client / Consultant HSE rules/Plan.
 High risk work e.g. hot work, demolition, excavation, working in confined spaces, working
at height, electrical work and any other specified work will not be started unless a 'permit
to work' has been obtained. For hot work only, work area must be checked one hour
after completion of the works.
 If in the opinion of Client / Consultant, Contractors are working in such a manner
as to put themselves, employees, visitors any other person, or property and equipment
at risk, the contractors can be requested to stop work immediately and rectify the
controls.
 HNE / Contractors must supply their own PPE, access equipment, electrical equipment /
tools and hand tools.
 HNE will ensure these terms and conditions are communicated to all their
employees working at Company premises.
 HNE / Contractor must immediately implement appropriate corrective / preventive actions
for any safety issues identified.
 Where a HNE / sub contractor employee has been violating safety rules even after being
issued with a written warning letter (safety violation), he / she along with his
supervisor shall be summoned to the HNE Office; issued with a termination order by
the Company HSE Manager and both will be asked to leave the Project premises. The
Contractor shall replace the employee with an alternative employee with the same or
more competency

I have read the above conditions and accept them.

Signed: ......................................................, Position: ......................................................

On behalf of:.............................................., Date: ............................................................

HNE-HSE-F-01 Page 1 of 1 R: 0 D: 01-07-2012

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 TOOL BOX TALK RECORD
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 Contractor/Subcontractor Name: Date:
Following points were discussed in today’s toolbox talk:
a)
b)
c)
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d)
Following persons attended the session:

SL No: Card Number* Name Designation Signature

(* If this pertains to the sub contractor employees, indicate the name of the
contractor) Toolbox talk was given by:
Name :
Position :
Signature :

HNE-HSE-F-02 Page 1 of 1 R: 0 D: 01-07-2012

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 HSE REVIEW MEETING REPORT
HSE Meeting Number:
Members Present Distribution of Minutes

Place:
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Date: Time:
Minutes recorded by: Signature:
Action by Closed
Sl.
Description / Target out (Date
No
Date & Sign)
1. Purpose and objective of the meeting:

2. Previous meeting points:

3. Housekeeping (Edge Protection/ Slab penetration, signs etc):

Housekeeping:

Edge Protection:

4. Welfare measures:

Rest Area:
Toilets:
Drinking Water:
5. Safety Incentive Scheme:

Safety improvement slips:

Suggestion Received:
6. Accidents/ Incidents/ FA cases:

7. Scaffolding and ladders:

a. Scaffolds:
b. Ladders:
8. Electrical safety:

9. PTW issues:
1. Hot Work:
2. Barricade Removal Permit System:
3. Excavation
4. Confined Space
5. LOTO

10. HSE Inspections:

11. Induction and Tool box talks:

12. Fire Prevention:

HNE-HSE-F- Page 1 of 2 R: 0 D: 01-07-

03 2012

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 HSE REVIEW MEETING REPORT
13. Emergency preparedness:

14. Lifting Tools & tackles / Hoists:

15. Plant & machineries:

16. Safety training and awareness sessions:

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17. Risk Assessments:

18. Sub contractors: -

19. Scope for possible improvement in HSE:

20. Environmental Issues:

1. Spillage –
2. Waste Water –
3. Noise –
4. Dust -
5. Construction Waste –
6. Chemical Waste –
7. Chemical Storage –.
8. MSDS –

21. Authorities Issues:

22. Safety audit, if any:

23. Storage / Resource:

24. PPE:

25. Security:
26. Any other issues:
27. Next meeting:

Next Meeting Date:

HNE-HSE-F- Page 2 of 2 R: 0 D: 01-07-

03 2012

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 HSE OBSERVATION REPORT

Contractor :

Date :

SL
OBSERVATIONS ACTION TAKEN
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NO

Inspected By :

Report To :

This report shall be returned within 24 hours to the Contractor’s Safety Personnel
indicating action taken against the observations made.

HNE-HSE-F- Page 1 of 1 R: 0 D: 01-07-

04 2012

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 ENVIRONMENTAL INCIDENT REPORT
Contractor :
Time of Incident :

Date of Incident :
Air Emission
Water Pollution (Wastewater Discharges / Sanitary Waste)
Solid or Hazardous Waste
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Hazardous Materials or Chemicals Used / Stored

Noise Pollution
Odour / Dust
Water / Fuel / Electricity Consumption
Other
Details of Incident

Reported By Date
Root Cause

Investigated By Date
Action Taken

Taken By Date
Review & Close out

Carried out By Date

HNE-HSE-F-05 Page 1 of 1 R: 0 D: 01-07-2012

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 CORRECTIVE ACTION REQUEST
Contractor :
Date :

CAR Ref :

Nonconformity Minor Major Observation

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Raised By Date
Results of Investigation & Root Causes

Investigated By Date
Corrective Action

Action Taken By Date

Follow-up Comments

Carried out By Date

HNE-HSE-F-6 Page 1 of 1 R: 0 D: 01-07-

2012

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 COURSE ATTENDANCE SHEET
Course Title

Date

Trainer
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Sl Name Designation Company Staff No: Signature

Trainer Signature :

HNE-HSE-F-7 Page 1 of 1 R: 0 D: 01-07-

2012

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 TRAINING CALENDER

Year

Course Title Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
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HNE-HSE-F-8 Page 1 of 1 R: 0 D: 01-07-

2012

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 Date Planned
Updated on:
Date Completed

Signature:
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HNE-HSE-F-8 Page 1 of 1 R: 0 D: 01-07-

2012

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 FIRE EXTINGUISHER INSPECTION REPORT

Pr Gauge
Location

Safety Clip

Remark/Sign
ConditionHose

InspectionDate Of
Inspection 3rd Party
Sl Type Of Fire
no Extinguisher
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Inspected by :

Signature :

Date :

HNE-HSE-F-9 Page 1 of 1 R: 0 D: 01-07-

2012

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 SAFETY VIOLATION NOTICE
Warning Notice No: Date
Contractor Location
Warning issued to:
Name:
Card / Staff No: Designation:
Approximate
Date and Time:
Location:
You were found working unsafely at site, which could have resulted in serious accident and
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thus injuring you and / or others. The violation is as follow:

You were found working unsafely / allowing the operatives working under you to carry out
work in on unsafe manner thus putting in danger their lives as well as others working nearby.
The violation is as follow:

Is the violator given sufficient training related to the type of violation [Yes / No]
Safety training (Induction, specific training) reference to be attached with reference to the type
of safety violation.
This is against our company safety policy and the local rules governing the Health and Safety of
employees. The following action will be taken against you:
Repetition Nos. Action Taken
st The employee will be called during the toolbox talk and will be asked to address others the
1 Warning
circumstances in which he was forced to take the shortcut (follow the unsafe practice) and
/
how it can be avoided; he has to also apologize for the said act and promise the whole
Repetition
group that he will not repeat the same in future
nd
2 Warning Concerned employee along with his supervisor will be asked to report to the Company HSE
/ Manager. Contractor HSE Officer shall coordinate this. After appropriate counselling, both
Repetition of them will be issued with a warning letter.
The Contractor employee, along with his supervisor shall be summoned to the Company
Office; issued with a termination/ de-mobilized notice by the Company HSE Manager and
shall not be allowed to work within the Company premises.
rd
3 Warning Any Contractor staff found working within the Company premises without a valid (UAE)
/ work permit; he/she along with his supervisor shall be issued with a termination/ de-
Repetition mobilized notice immediately by the Company HSE Manager and will be asked to leave
Company premises. Contractor will be given 24hours to submit the original work/permit to
Company HSE, failing which contractor will be asked to permanently demobilize the
identified staff and his immediate supervisor from the site.
Safety violation noticed by: Safety Warning issued by: Warning Accepted by:
Name:
Designation:
Signature:

HNE-HSE-F-10 Page 1 of 1 R: 0 D: 01-07-

2012

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 MOBILE CRANE ENTRY PERMIT
Contractor Name: Date: Permit No:
Vehicle No: Capacity: Place:

SL Check Points Yes No Remarks

Section 1: Document Verification (Mandatory) – to be checked by site engineer
1 UAE valid Crane Registration with at least one month validity upon
entry
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2 UAE valid Driving License of the operator

3 Valid Third Party test Certificate for crane (Every 12 Months)
4 Valid Operators Third Party Competency Certificate
5 Test certificate for the Lifting Gear available in the crane
Name & Signature:
Section 2: Physical Condition of Equipment – to be checked by Site engineer / Site Supervisor
1 Display/Availability of Load chart in crane.
2 Automatic safe load indicator/ Top Limit Switch
3 Audible alarm linked to safe load indicator
4 Automatic Reverse Horn
5 Out riggers with base supports in good condition
6 Rear /Side view mirrors (as Applicable)
7 Free from Hydraulic Oil Leakage /Diesel
8 Availability of safety Latch in the slings and lifting hook
9 Warning Lamps /Lights (Night Working)
10 Proper functioning of control levers/brakes/Steering
Name & Signature
Section 3: Operators Assessment - to be checked by Safety
1 Site safety rules and norms
2 Safety awareness & Emergency Preparedness
3 Knowledge of job to be executed.

HNE-HSE-F-11 Page 1 of 1 R: 0 D: 01-07-

2012

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 MOBILE CRANE ENTRY PERMIT
Equipment is Authorized to enter the site
Name:
Signature:
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HNE-HSE-F-11 Page 1 of 1 R: 0 D: 01-07-

2012

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 HOT WORK PERMIT
Contractor Name: Date: Permit No:
Name of the sub contractor (if applicable):

Section I: (To be filled by authorized Receiver)

Location of the hot work (indicate level and grid no and enclose location sketch if required):

Description of the work: Arc welding / C utting / Grinding near flammables / Soldering / Brazing
/Metal cutting / Electric Cable termination and jointing
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Section II:(Request for the permit) Permit Receiver to mark all boxes either with  (only for
relevant ones) or mark as X
 No flammable/combustible materials around/below  Suitable Fire Extinguisher and trained personnel
the work spot. (Operation of Fire extinguisher) at the work place
 Wet gunny bag/fire resistant sheet to arrest flying spark  Welding m/c with proper insulated welding
cable/lugs
 Standby person for watching falling molten metals.  Welding & supply cable without joints/ damages.
 Gas cutting torch fitted with Flash back arrestor.  Separate Ele. supply cable with ELCB from DB
 Soap water test conducted for detecting leakage.  No criss-cross of power & welding cables
 Gas Cylinder with proper Pressure Gage & Regulator.  Proper/overhead routing of Electrical cables
 Gas Cylinders with Chain/ trolley to arrest falling.  Availability of proper scaffolding/platform/ladder
 Gas Hose of sound condition & proper hose clips.  Proper ventilation
 Suitable Spark lighter available- never use smoking lighter.  Separate permit incase of work in confined space
 Barriers to avoid exposure of UV / IR rays to passers  Safety inducted welder / Helper and others involved
 Do not gas cut containers of flammable liquids.  Required PPE for helper
 PPE - Helmet  Welding Screen  Suitable Goggles  Welding Apron
 Dust Masks  Leather Hand Gloves  Safety Shoes  Full Body Harness
Any other precautions (Specify):

I request for a Hot Work Permit for the above-mentioned work at the location specified
above. I have personally inspected the work place to ensure that the applicable precautions
mentioned above have been complied with.

Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):

Name: Signature:
Section III: (Permit Approval - To be filled by authorized Issuer)
I have personally verified the work spot and compliance of the relevant precautions given in
section II of this permit.

The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).

Name of the concerned engineer (Authorized Issuer): _ __ _ _ Signature: _ _ _ _ _
Section IV: (Permit close out cum Revalidation details)
(To be returned to the authorized approving authority immediately after the completion of work for
closing / revalidation at the end of the work everyday)
Revalidation dates
Sign of Receiver for proper closing the
work with time.
Sign of Receiver for proper starting the work
on next day with time.
Sign of Issuer for proper starting the work on
next day with time.
Note:
1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety
2. The permit must be registered and a unique number to be given for each permit for follow up.
3. This permit is not valid for cutting containers of flammables.
4. This permit is valid for the location mentioned in section I and for one day only. Can be
revalidated (if location is not changed) on a daily basis for a maximum period of one
week.
5. Permit can be cancelled at any time if any violation observed.

HNE-HSE-F-12 Page 1 of 1 R: 0 D: 01-07-

2012

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 CONFINED SPACE ENTRY PERMIT
Contractor Name: Date: Permit No:
Name of the sub contractor (if applicable):

Section I: (To be filled by authorized Receiver)

Location of the work (indicate level and grid no and enclose location sketch if required):

Description of the work /Reason for Entry:

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Section II:(Request for the permit) Permit Receiver to mark all boxes either with  (only for relevant
ones) or mark as X
 Suitable & Sufficient access provided to the confined
 All the employees trained in working in confined space?
space?
 Required warnings signs (Danger – Restricted Entry,  Gas test been done to check the absence of flammable
Permit Required), Emergency Contacts no displayed gases
 If any other gases are anticipated, has it been checked?  Have low voltage & flameproof lighting been arranged?
 Confined space checked for oxygen deficiency  All concerned persons been informed
 Enough ventilation ensured.  Entrants provided with emergency lights
 A stand-by (Buddy) is deputed outside the manhole /  In-Out Register ready to maintain / Available with
confined space buddy
 All entrants provided with safety harness with long
 Necessary safety appliances been provided
lifeline
Any other precautions (Specify):
LEL

Oxygen
I request for a Confined Space Entry Permit for the above-mentioned work at the location
specified above. I have personally inspected the work place to ensure that the applicable
precautions mentioned above have been complied with.

Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):

Name: Signature:

Section III: (Permit Approval - To be filled by authorized Issuer)

I have personally verified the work spot and compliance of the relevant precautions given in
section II of this permit.
The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).
Name of the concerned engineer (Authorized Issuer): _ __ _ _Signature_ _ _ _ _ _ _

Section IV: (Permit close out - To be filled by authorized Receiver)

(To be returned to the authorized approving authority immediately after the completion of work)
The said job is completed and all the entrants have come out from confined space.
Name(Authorized Receiver): Signature:

Date and Time:

Note:
1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety
2. The permit must be registered and a unique number to be given for each permit for follow up.
3. Percentage of O2 should not be less than 20%
4. This permit is valid only for the location mentioned in section I and for one day only.
5. Permit can be cancelled at any time if any violation observed.

HNE-HSE-F-13 Page 1 of 1 R: 0 D: 01-07-

2012

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 ELECTRICAL ISOLATION PERMIT
Contractor Name: Date: Permit No:
Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)
Location of the work (indicate level and grid no and enclose location sketch if required):
Test Description: Test Equipment:

Section II:(Request for the permit) Permit Receiver to mark all boxes either with  (only
for relevant ones) or mark as X
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 Sufficient training conducted for concerned staff and

 Competent working crew has been deputed
documented
 Power supply switched off  Circuit breaker Deactivated
 Isolator switch locked*  Required warning notices” DANGER”, “RESTRICTED
ENTRY”, “HIGH VOLTAGE TESTING IN
 Earthing available
PROGRESS”,
 All testing equipments are calibrated and
 All floor & roof openings are covered and barricaded
sticker available
 Stand by (Buddy) Provided  Emergency Contacts are displayed.
 Fiber ladder is available for testing work.  Testing area identified and barricaded
 Area is free from flammable and
 Suitable Fire Extinguishers are provided
combustible materials
 ELCB available with supply source DB  Illumination is sufficient
 Necessary safety appliances provided  Unauthorized entry is restricted by suitable means
Any other precautions (Specify):

I request for a Pre Commissioning Testing Permit for the above-mentioned work at the
location specified above. I have personally inspected the work place to ensure that the
applicable precautions mentioned above have been complied with.

Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):

Name: Signature:

Section III: (Permit Approval - To be filled by authorized Issuer)

I have personally verified the work spot and compliance of the relevant precautions given in
section II of this permit.

The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).

Name of the concerned engineer (Authorized Issuer): _ __ _ _ _Signature _ _ _ _ _ _

Section IV: (Permit close out - To be filled by authorized Receiver)

(To be returned to the authorized approving authority immediately after the completion of work)
The said job is completed and the equipment is safe for re-energizing.
Name(Authorized Receiver): Signature:

Date and Time:

Note:
1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety
2. The permit must be registered and a unique number to be given for each permit for
follow up.
3. All dead cables shall be terminated with insulation properly during / after test.
4. This permit is valid only for the location mentioned in section I and for one day only.
5. Permit can be cancelled at any time if any violation observed.
6. *- The key shall be available only with the technician performing the job

HNE-HSE-F-14 Page 1 of 1 R: 0 D: 01-07-

2012

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 EXCAVATION PERMIT
Contractor Name: Date: Permit No:
Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)
Location of the work (indicate level and grid no and enclose location sketch if required):
Description of the work:

Section II:(Request for the permit) Permit Receiver to mark all boxes either with  (only
for relevant ones) or mark as X
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 Required permit for buried services has been  Workers are given training – Risk Identification
obtained from the concerned authority. and Precaution
 Are all the buried services located (with the  Required caution boards / warning notices are
help of drawings and by trial pit, detectors etc) provided
 Is Shoring / sloping required? If so, has the  Barricades / Handrails installed around the
material been arranged? proposed excavation site
 The access details to the pit finalized and  Are any traffic diversion signs / flashers required If
materials arranged accordingly yes are these items provided?
 Following additional precautions shall be taken after taking up the excavation work: (Tick relevant boxes
alone)
 Verification of the condition of shoring at regular intervals
 Usage of PPE such as
 Verification of the condition of handrails, access, flashers etc
 Storage of surplus earth at least m away from the edges of excavation
 Block stops at the edges of excavation to limit the access of vehicles
 Emergency escape (evacuation procedures)
 Construction equipment exhaust away from excavation

I request for an Excavation Permit for the above-mentioned work at the location specified
above. I have personally inspected the work place to ensure that the applicable precautions
mentioned above have been complied with.

Name & Signature of the Authorized Receiver (Engineer / Supervisor/ foreman):

Name: Signature:

Section III: (Permit Approval - To be filled by authorized Issuer)

I have personally verified the work spot and compliance of the relevant precautions given in
section II of this permit.
The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).
Name of the concerned engineer (Authorized Issuer): _ __ _ _ _Signature_ _ _ _ _ _

Section IV: (Permit close out - To be filled by authorized Receiver)

(To be returned to the authorized approving authority immediately after the completion of work)
Name(Authorized Receiver): Signature:

Date and Time:

Note:
1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety
2. The permit must be registered and a unique number to be given for each permit for
follow up.
3. Ensure the no residual risk after completion of work.
4. This permit is valid only for the location mentioned in section I and for one day only.
5. Permit can be cancelled at any time if any violation observed.

HNE-HSE-F-15 Page 1 of 1 R: 0 D: 01-07-

2012

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 PERMIT TO WORK REGISTER
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SUB - REVALIDATION / CLOSING STATUS

PERMIT PERMIT LOCATION ISSUER RECEIVER
CONTRACTOR
DATE NUMBER TYPE NAME NAME (if any) WRITE REVALIDATION DATE

HNE-HSE-F-16 Page 1 of 1 R: 0 D: 01-07-2012

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 INCIDENT NOTIFICATION FORM
Contractor Name: Date :
Employee Name (s): Card No / Staff No:
Age: Designation /
Contact Number: Category:
Name of the Concerned Engineer/Foreman:
Contact number concerned engineer/foreman:
Witness of Accident (Name, Designation, Contacts):
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Person (s) Involved:

Card No / Staff No Name Designation Employer

Circumstances and brief description of the Incident / ill health:

Immediate Action taken after the Incident / ill health:

Injury / Illness Details:

Nature / Extent of Injury or Illness /
Disease:
Location of Accident:
Date & Time:
Present Condition:
Referral Details (If applicable):
Hospital / Clinic:
Ward No / Bed No:

First Aid Provider Safety Engineer / PM / CM

Name & Signature

Note: This form is to be filled immediately in case of injury / illness immediately and submitted
to Company HSE Personnel.

HNE-HSE-F-17 Page 1 of 1 R: 0 D: 01-07-2012

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 HSE INCIDENT REPORT
Employee Date of Incident
Name
Job Title Time of Incident
Type of Injury
Lost Time Injury Yes No Nature of Injury Major
Minor
No. of Days/ hours Lost
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Property Damage Yes No Extent of Damage

Incident Description

Primary Cause

Contributory Factors
Protective Equipment not used Yes No Inattention Yes No
Protective Equipment not Yes No Fatigue Yes No
available
Identified controls and given Yes No Defective Equipment Yes No
instructions not followed
Lack of Communication Yes No Poor Judgment Yes No
Lack of Training Yes No Poor Housekeeping Yes No
Contributory Negligence by Yes No Shortcuts Yes No
Others

Reported By: Date

Action Taken

Reviewed By: Date

This report to be submitted to the Company HSE personnel by the contractor within 24 hours for all HSE
incidents (accidents & near miss)

HNE-HSE-F-18 Page 1 of 1 R: 0 D: 01-07-

2012

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 INCIDENT INVESTIGATION REPORT
Section 1 - Incident Details:
Incident Investigation Report No
Date of Incident
Time of Incident
Exact Location of Incident
Nature of Incident Over 2 Days
Hospital referral case (< 2 days)
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Fatality
Dangerous Occurrence / Nearmiss
FIRE
Property Damage
Environment Disturbance
Other (specify)
Type of injury (If any) : Bruise Sprain
Fracture Cut
Amputation Crush
Burn Electric Shock
Puncture wound Heat Related Illness
Eye Injury Other (State)

Details of Damage (If any):

Details of the plant / Equipment

involved in the Incident:
Incident Reported By (Name and
Position):
Section 2 – Injured Person (s) Details:
Name (s):
Name of Sub Contractor (If any):
Card No / Staff No:
Designation / Category:
Age:
Experience:
Training Attended / Experience:
Include the induction, related TBT, job
specific training given – attach records

HNE-HSE-F-19 Page 1 of 4 R: 0 D: 01-07-

2012

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 INCIDENT INVESTIGATION REPORT
Section 3A – Person Involved (Details):
Name of Sub Contractor (If any)

Name of Concerned Engineers:

Name of the person involved:
Designation / Category:
Card No / Staff No:
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Age:
Section 3B – Witness Details:
Name Position Contact No Company

Section 4 - Circumstances and description of the Incident:

Section 5 – Facts observed during investigation:

Section 6 – Casual Factors:

Immediate / Underlying Cause Root Cause

Section 7 – Control measure present while Incident:

HNE-HSE-F-19 Page 2 of 4 R: 0 D: 01-07-2012

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 INCIDENT INVESTIGATION REPORT

Section 8 – Recommendation / Action to be taken to avoid recurrence:

Target Close out
Sl. Recommendations
Date date
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Incident investigation conducted by, Submitted to,

Name Designation Signature

Project Manager /
Construction
Manager
Add pictures of Incidents
Picture 1 Picture 2

HNE-HSE-F-19 Page 3 of 4 R: 0 D: 01-07-2012

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 INCIDENT INVESTIGATION REPORT
Picture 3 Picture 4
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Distribution:

HNE-HSE-F-19 Page 4 of 4 R: 0 D: 01-07-2012

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 SUGGESTION/NEAR MISS/
UNSAFE ACT/ UNSAFE CONDITION CARD

Contractor Date
Employee Name Location.

Section 1: Problem Description (Please write what you observed, you may write in any language)
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Section 2: What is your suggestion / recommendation to eliminate the problem?

Section 3: Expected benefits from your suggestions:

Section 4: Reviewer - Safety Supervisor/Safety Manager

Section 4: Comments from Client Project Director

Staff/Card No Name Designation Signature

HNE-HSE-F-20 Page 1 of 1 R: 0 D: 01-07-2012

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 SAFETY VIOLATION REGISTER
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Detail of the Violator: Details of the Violation: SI Slip

Name of the
Sl Employee Card Exact Issued Remarks
Company Name Date Description of the Violation supervisor
No Name number* location By

Note: * If the violator belongs to a sub contractor, indicate the name of the company.

HNE-HSE-F-231 Page 1 of 1 R: 0 D: 01-07-2012

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 FIRST AID REGISTER
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Detail of the injured: Details of the accident:

Part of Date and time Name of the
Card Exact Brief Description of Remarks
SL Name Category Age Date Time body of returning supervisor
number* location the Accident**
injured back to work

* If the injured belongs to a sub contractor, indicate the name of the company.
** Mention what the injured was doing, the equipment, material he was handling at the time of accident etc.

HNE-HSE-F-242 Page 1 of 1 R: 0 D: 01-07-2012

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 HSE WEEKLY INSPECTION CHECKLIST

PROJECT NAME:
Sl No Description Observation Remarks Action By

EXCAVATION
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SCAFFOLDS

CONCRETING

WORK AT HEIGHT

MATERIAL HANDLING

GRINDING

WELDING & GAS CUTTING

PLANT & MACHINERY

HNE-HSE-F-253 Page 1 of 2 R: 0 D: 01-07-2012

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 ELECTRICAL SAFETY
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FIRE PROTECTION

HOUSEKEEPING

PERSONAL PROTECTIVE EQUIPMENT

HEALTH & HYGIENE

ENVIRONMENT

SIGNATURE WITH DATE :

HNE-HSE-F-23 Page 2 of 2 R: 0 D: 01-07-2012

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 EMERGENCY PREPAREDNESS – CONTACT LIST

NAME DESIGNATION TELEPHONE NUMBER

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Updated On:
Updated By:

HNE-HSE-F-274 Page 1 of 1 R: 0 D: 01-07-2012

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 HSE INDUCTION RECORD

Company: Date: Time:

Important Note: When you sign below you are agreeing that you have understood
induction and that you know the site regulations on the topics listed below:
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- Project Details - Accident Reporting - Excavation Safety

- Saverglass HSE Policy - Emergency Numbers - Traffic Management
- First Aid arrangements - Housekeeping - Smoking Policy
- Medical Facilities - Fire Prevention - Evacuation Procedure
- Accident Prevention - Hot Work Permits - PPE

Sl Name Company Designation Signature

10

Induction By: Name Sig. Date

Witnessed By: Name Sig. Date

HNE-HSE-F-285 Page 1 of 1 R: 0 D: 01-07-2012

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 DOCUMENT DISTRIBUTION RECORD

Document Issued to
Sl Name of the Document
Name / Title Date Signature
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HNE-HSE-F-296 Page 1 of 1 R: 0 D: 01-07-2012

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